Informed Consent Form

You are being asked to participate in a survey research project entitled Hospice Residence Facility Feasibility with St. Lawrence County, which is being conducted by Dr. Jennifer Ball, a faculty member at Clarkson University. This survey is confidential. Your responses will not be associated with your identity.

The purpose of this study is to gather information about the public’s opinion of hospice. There are no anticipated long-term risks to you related to your participation in this study. Some of the questions in this survey may cause you to recall unpleasant or emotionally upsetting experiences. If you feel you need to speak with a professional counselor about these memories or your response to them, you may contact Hospice and Palliative Care of Saint Lawrence Valley at (315)265-3105 and ask for Grief Support for help.

Your participation in this survey is voluntary. You can choose to refrain from answering any particular question at your discretion. You may choose at any time to end your participation in the group or refuse to participate in the study without penalty or loss of benefits to which you are otherwise entitled.You must be at least 18 years of age to participate in this study. You are encouraged to ask questions regarding this form to the interviewer. Your participation in survey serves as your voluntary agreement to participate in this research project and your certification that you are 18 or older.

Questions regarding the purpose or procedures of the research should be directed to the principal investigator Dr. Jennifer Ball, who may reached by phone at (315)268-4208 or by email This study has been approved by the Clarkson University Institutional Review Board (IRB) review in accordance with Federal regulations. The IRB, a university committee established by Federal law, is responsible for protecting the rights and welfare of research participants. If you have concerns or questions about your rights as a research participant, you may contact the IRB Administrator, Johndan Johnson-Eilola, Associate Chair of the IRB for human subject research at (315)268-6488 or

* 1. Are you a resident of St. Lawrence County?

* 2. Do you have family or friends in the St. Lawrence County area?

* 3. A caregiver is a relative or friend who provides regular care for a hospice patient.
End-of-life care is the medical care given to a patient in the final stages of life.

Can you identify someone who would be your caregiver if you should need end-of-life care?

* 4. Has anyone close to you used hospice or end-of-life care?

* 5. As family and friends age, where would you go to find information about their care? (Check all that apply)

* 6. Do you have health insurance, and if so, who is the provider? 

* 7. If a family member needed end-of-life care, would you be comfortable placing them in hospice care? Why or why not?