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American Association for Public Opinion Research

Physician Practice Issues

Written Consent Incorporated into Cover Letter for Self-Administered or Web Survey with Telephone Interview Follow-Up – Physician Practice Issues

Dear Dr. XXXXX:

We are writing to invite you to participate in an evaluation research project. The XXXX Department of Public Health is gathering information from XXXXX’s citizens and primary care providers regarding Colorectal Cancer (CRC) Screening. The objective for the information gathered from the providers is to develop valid recommendations for CRC screening practices. These recommendations will eventually be made to the Centers for Disease Control and Prevention, which is funding these research projects.

Information from the providers will be gathered from surveys of 750 primary care providers and a follow-up interview of a subset of approximately 75 unique primary care practices. Of the 750 providers, 90 will be OB/GYN physicians. The survey data are being collected by the [INSERT ORGANIZATION] under the direction of [INSERT DIRECTOR]. Completion of the survey should take no more than 15 minutes. The interviews will be conducted by investigators from the [INSERT ORGANIZATION] under the direction of [INSERT DIRECTOR] and will only be completed if you explicitly provide permission for the follow-up contact to your practice. Completion of this interview should take no more than 15 minutes and may be completed by one of your designated staff members by either FAX or telephone.

Responses to the survey and interview will be confidential and no identifying information will be stored with your responses. Other than your time, the project will not involve any financial costs and no foreseeable risks beyond those encountered in your normal day-to-day activities. There is no direct benefit to participation but the information provided will be the foundation for the development of recommendations and interventions which have high likelihood of improving your ability to deliver CRC screening. As a small token of our appreciation, we are enclosing a pre-paid phone card that you may keep regardless of your decision to participate.

Your participation is voluntary. A stamped and addressed envelope has been enclosed to for your convenience. An arbitrary tracking number is affixed to facilitate survey tracking so that multiple mailings to you can be avoided. We would appreciate your returning the survey within the next 10 days. We will send a reminder card and a second mailing to those not responding initially. If you would prefer, you may complete the survey on the web at http://xx/xxxxxx using the ID XXXXX to log in. Please complete the survey using only one mode (i.e., web OR paper).

If you have any questions about the survey content, please don’t hesitate to call [INSERT CONTACT] who may be reached at XXX.XXX.XXXX or by email at [email protected] If you have questions about the survey administration, please contact [INSERT CONTACT] by email at [email protected] or by phone at XXX.XXX.XXXX. If you have questions about the rights of research subjects, please contact the Human Subjects Office, XXXXXXXXXX, The University of XXXXXX, City, State, Zip, xxx.xxx.xxxx, or e-mail [email protected] General information about being a research subject can be found by clicking "Info for Public" on the Human Subjects Office web site, http://xxxxxxxx.xxxxxx.edu/hso.


(Principal Investigator)