Examination of the Effect of Implicit Bias and Perceived Discrimination on the Provision of Health Care amongst African American women Healthcare Provider Key Informant Interview Registration Form

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Examination of the Effect of Implicit Bias and Perceived Discrimination on the Provision of Health Care amongst African American women Healthcare Provider Key Informant Interview Registration Form

Thank you for your interest! Please complete the questions below and someone from the Institute will be in contact with you regarding your registration.

Email *

Name *

Phone Number *

Race *

Black

White

Asian

Hispanic

Other

Other:

What is your age? *

Are you a Mississippi resident? *

Yes

What Mississippi county do you currently live in? *

Are you a Healthcare Provider ? *

Yes

If you answered yes to the previous question please specify. *

Physician

Physician Assistant

Nurse Practitioner

Pharmacist

Other

Other:

What Mississippi county do you currently work in ? *

“Examination of the Effect of Implicit Bias and Perceived Discrimination on the Provision of Health Care amongst African American women ages 18 and older in Mississippi”

Informed Consent Form

Description of the Study: You are being invited to participate in a research study entitled “Examination of the Effect of Implicit Bias and Perceived Discrimination on the Provision of Health Care amongst African American women ages 18 and older in Mississippi”. This study is being conducted by the Institute for the Advancement of Minority Health which is a 501(c)3 non-profit, public health organization dedicated to improving the lives of vulnerable, disadvantaged minority individuals in Mississippi.

Purpose of the Study: The purpose of this research study is to determine the impact of implicit bias and perceived discrimination on accessibility and availability of health care services, among African American women ages 18 and older in Mississippi.

Voluntary Participation: Your participation in this study as a key informant is voluntary. You may refuse to take part in the research study or refuse to answer any question during the interview at any time without penalty. Your answers will be documented by the research group and your responses will remain anonymous.

Incentives: As a participant, you will receive a $50 gift card upon completion of the interview.

If you have any questions or concerns please call or email the researcher Warren Jones at 424-312-5866 or wjones@advancingminorityhealth.org

By entering your name below, you are agreeing that you are 18 years of age or older and that you consent to participate in this study

By checking the box below, you are agreeing that you read the consent form , or it has been read to you, and you fully understand the contents of this document and are willing to take part in this study.

I agree

I disagree

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