MFHP Consent Form

Form Approved

OMB Control No. 0920-1050

Exp. Date: 06/30/2025

ATTACHMENT 2

Consent Form for MFHP Usability Study

Consent Form

We are interested in your feedback!

We would like to know what you think about Centers for Disease Control and Prevention’s (CDC) My Family Health Portrait: Cancer (MFHP: Cancer) app.

We want to know how well the app works for people to collect their personal and family health history and learn their risk of cancer. This information will help us make the app even better in the future.

Here is what to expect.

1. Before the study: We will meet with you before the study to explain what to expect and introduce you to the app. This meeting will take place virtually and should last about 30 – 60 minutes.

2. Every week (for 4 weeks): We will ask you to complete some tasks on the app every week. You will get instructions emailed to you weekly, and you may complete the tasks at whatever time works for you within the requested time frames.

3. Every week (for 4 weeks): We will ask you to take short surveys to collect your feedback about your experiences. Links to these surveys will also be emailed to you and you may complete them whenever you want within the requested time frames.

4. After the study: We will meet with you to talk to you about your overall experiences with the app. This meeting will take place virtually and should last about 30 – 60 minutes.

While the amount of time needed for the tasks varies, please expect to spend about 1 hour per week completing the task(s) and filling out the related survey.

Being in this study is completely voluntary. You can choose not to participate or leave at any time, with no bad effects. The sessions will NOT be recorded, but we will be taking notes about your feedback and experiences.

Your answers will only be used to make the MFHP: Cancer mobile app better in the future. Your answers will not be shared outside of the study team.

While this app does use personal data that is entered, such as your medical history, we do not collect or store any clinical (medical) data. We will only be collecting and storing the responses and feedback you provide in the study surveys. Your responses and feedback will not be published or used for any other purposes other than the improvement of the MFHP: Cancer app. Since we will be storing the survey responses, please do not include any personally identifiable information in any of your answers. This includes any information which can be used to identify you, such as your full name, address, social security number etc.

The results you get using the app will remain confidential, and you do not have to take any more steps after using the app to finish the study. Please remember that the app results do not replace advice from a doctor or health care provider, and we encourage you to speak to a health care provider if you have any questions or concerns about the results you get.

If you agree to be in this study , please sign below.

Thank you for your time.  Your feedback is very important to us! 

Name: _________________________________________________

Signature: _______________________________________________

Date: ___________________________________________________

*If at any time you wish to leave the study and stop participating, or have any further questions, please contact [moderator] at [moderator email] or [moderator phone]