Appendix F - KAZ Consent Form_Apr2

4/3/2007

OMB No.:0925-XXXX and Expiration Date: XX/XX/2010

Appendix F

Focus Group Participant Informed Consent Form
Kazakhstan Dairy Consumption and Agricultural Practices
Staff from the United States National Cancer Institute (NCI) are working with the
Semipalatinsk State Medical Academy to learn more about the activities of daily
life in Kazakhstan during the time of the nuclear testing from 1949-1962.
You will be taking part in a focus group interview. A focus group interview is a
group discussion where we ask you to recall and describe events that took place
between 1949 and 1962. You will be asked about dairy products that people ate
and drank, daily activities of children in your village, living conditions, and how
dairy animals were tended in your village. There will be up to 8 people
participating in the group. There are no right or wrong answers, we just want you
to try to recall as best you can and also give us your opinions about dairy products
that people ate and drank and agricultural practices at that time.
Your participation in this group discussion is voluntary and you may ask to stop at
any time. Your participation and any comments you make will be kept
confidential. Comments from all people taking part in these discussions will be
combined in a summary report that will not identify any one person. This group
discussion will last two hours.
What you say will be recorded on paper forms by a note-taker and on an audio
recording device. Your name will not appear on any forms and information about
your personal information will not be connected to your remarks in any way. We
will be audio recording this focus group in order to more easily prepare our
summary report. The audio files will be destroyed after the study is complete.
You will be paid $5.00 for taking part in this group discussion.
There are no physical risks to you from taking part in this group discussion other
than those you would have in daily life. You do not have to be in this study. It’s
okay to stop even after we begin. There will be no bad feelings. No one will be
angry or upset with you. There are no direct benefits to you from participating in
this group discussion. Please ask as many questions as you need to make sure you
understand this study before you sign this form.
If you have any questions later about the study, you may call Dr. Zhaxibay S.
Zhumadilov with SSMA at 7-3222-561604.
Appendix F - KAZ Consent Form_Apr2

4/3/2007

OMB No.:0925-XXXX and Expiration Date: XX/XX/2010

If you have any questions about your rights as a study participant, you may call
SSMA’s IRB Chairperson, Dr. Raifa L. Ivanova, at 7-3222-531891.

If you decide you want to be in this study, please print and sign your name.
With my signature below, I agree that this information has been explained to me, I
understand my role in the group discussion, and I agree to take part in this group
discussion and its audio recording.

__________________________
Print your name here

_________________________
Date

__________________________
Sign your name here

_________________________
Date

__________________________
Moderator print your name here

_________________________
Date

__________________________
Moderator sign your name here

_________________________
Date

Appendix F - KAZ Consent Form_Apr2