Healthcare Content Testing Form

Healthcare Content Testing Form

Purpose and Scope

This form documents voluntary participation in the testing of healthcare-related content, tools, or media for the purpose of evaluating clarity, usability, comprehension, and clinical accuracy. Participation and any recordings or data collected will be used for quality improvement, product development, training, and compliance review as described below.

Patient Information

Patient Name:    Date of Birth:

Male   Female   Non-binary   Prefer not to say

Insurance Information

Medical History

Content Testing Details

Brochure/Printed Material   Video/Animation   Interactive Module   Consent Form/Legal Text   Telehealth/Script   Other:

In-person   Remote/Teleconference   Device(s):

Patient   Caregiver   Clinician   Other:

No   Yes — If yes, describe below.

Data Collection, Use, and Retention

The following types of data may be collected during testing. Check all that apply.

Responses / Survey Data   Audio Recording   Video Recording   Screen Capture   Eye-tracking / Biometric Data   Researcher Notes / Observations

Collected data will be handled in accordance with applicable privacy and confidentiality practices. Unless explicitly authorized below, personally identifiable information will be removed or replaced with a code prior to analysis. Data will be stored securely, access-limited to authorized personnel, and protected by technical and administrative safeguards.

Data will be de-identified: Yes   If de-identified: Describe method:

Authorization and Acknowledgments

By signing below, I authorize the collection and use of the data types checked above for the stated purposes (quality improvement, training, research related to content efficacy). I understand that participation is voluntary and declining will not affect my clinical care or access to services. I understand that I may withdraw this authorization at any time by submitting a written request to the testing coordinator; withdrawal will not apply to data already used or disclosed under this authorization prior to receipt of the revocation.

Authorization expires on:

HIPAA / Privacy Acknowledgment: I acknowledge that I have been informed of how my protected health information will be used and disclosed in connection with this testing. I understand that identifiable information may be disclosed to authorized project staff and collaborators for the purposes described above.

I acknowledge and consent to the uses and disclosures described above.

Risks, Benefits, and Rights

Risks: There are minimal risks associated with participation. Potential risks include temporary discomfort from being recorded or discussing personal health information, and the possibility of inadvertent disclosure despite safeguards.

Benefits: There may be no direct benefit to participants. Indirect benefits include improved clarity and accessibility of patient-facing materials which may benefit future patients.

Rights: Participation is voluntary. You may refuse to answer any question, stop participation at any time, and request that your recorded data be destroyed or excluded from analysis as described in the revocation procedure above.

Participant Consent

I confirm that I have read and understand the information above, have had an opportunity to ask questions, and voluntarily agree to participate in the content testing described in this document. I consent to the collection and use of data as indicated.

I consent to participate under the terms stated in this form.

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