Consent

Consent Form (for patient/proxy interview ONLY)
Influenza Hospitalization Surveillance Project
VERBAL CONSENT FORM
Hello. My name is __________ from the _____[state] Department of Public Health. May I speak to ______ [patient’s name
/parent of [child’s name] ] . We are working with the Centers for Disease Control and Prevention and other health
departments to learn more about influenza disease or the flu. To do this, we are talking to people who have been in the
hospital with the flu. We want to look at things that may affect their illness and whether they were vaccinated against the flu.
Because you/your child [or NAME if speaking with proxy] were in the hospital for the flu beginning on _______[day
admitted], I would like to ask you a few questions about whether you/your child [or NAME if speaking with proxy] received
the flu vaccine this season. This will take about five minutes. Your participation is voluntary and if you choose to refuse it
will not affect any medical care or benefits you receive. All of your responses will be kept confidential as much as the law
allows. You may refuse to answer any questions and may stop at any time. This information will help [State/Local Health
Department] and CDC better describe influenza-associated hospitalizations. Additionally, this information may help us
improve vaccination recommendations for flu and better protect the public’s health. There is no other benefit to you for
answering these questions. There is also no risk to you. If you have any questions about the study, you may call _____[state
contact] at the Department of Public Health at XXX-XXX-XXXX. Do you have any questions before I begin?
□ Yes

May I continue with this interview?

□ No

If YES, go to Appendix 7.
If NO: Thank you for your time. Have a good day.
Name of person obtaining verbal consent:
Date:

_______________________________
_______________________________
Flesch-Kincaid: 7.7

Case and Proxy Identifying Information
Influenza Hospitalization Surveillance Project
Patient’s:
Last name________________ First name____________ Initial__
Date of birth: ____/____/______
Phone_____________

Proxy’s:
Last name________________First name____________ Initial__
Phone_________________
Relationship to case patient _________________________
Note to collaborators: This is for your records only. Do not send this information to CDC. Keep this
information in a secure locked place.