Sample Verbal (Telephone) Consent Script:



Sample Verbal (Telephone) Consent Script:

Hello, my name is Dr. Jane Doe from the Division of Medicine at Hartford HealthCare Partner Institution. I am conducting a telephone research survey of established patients from my practice.

The purpose of this telephone research survey is to determine if …state general purpose here. I estimate that about X# patients treated at Hartford HealthCare Partner Institution for this same reason will participate in this telephone survey.

All the information I receive from you by phone, including your name and any other identifying information will be strictly confidential and will be kept under lock and key. I will not identify you or use any information that would make it possible for anyone to identify you in any presentation or written reports about this study. When I finish with all of the phone surveys from everyone who has agreed to participate, I will group all of the information together in any report or presentation. There will be no way to identify individual participants.

The only risk to you might be if your identity was ever revealed. There are no other expected risks to you for helping me with this study. There are also no expected benefits for you either.

Do you have any questions about this research study specifically?

All research on human volunteers is reviewed by a committee that works to protect your rights and welfare. If you have any questions or concerns about your rights as a research subject you may contact the Institutional Review Board at (860) 545-2893 or by email at irb@.

You may contact Patient Relations at (860) 545-1400 to confidentially discuss any problems, concerns, or questions with someone who is not affiliated with this research study.

Your participation in this survey is completely voluntary. This means that you do not have to participate unless you want to. Whether you choose to participate or not will not affect your current or future medical care in any way.

Would you be willing to answer one question today regarding the date(s) of birth of your children? Please remember, that all of your answers will be kept confidential and will not affect your current or future medical care.

(If yes, proceed; if no, thank them for their time and end the call).

( Yes, I voluntarily agree to participate in this research survey.

Subject Name: __________________________________

Date Verbal Consent Obtained: _____________________

Signature of Person Obtaining Verbal Consent: _____________________________

Date: _________________

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