Consumer Focus Groups on Physical Activity Guidelines, Submission #8

Consent Form

Under OMB No. 0990-0281, Prevention Communication Formative Research

Note to Focus Group Facility Staff:

Please read the About this Project and Participant Consent statements aloud to participants. Then ask each to provide a signature, printed name, and today’s date on the Participant Consent form.

About this Project

We have asked you to join a group of 7 or 8 people to talk about a few topics. The talk will last about 2 hours. A trained person will lead it. You will help health planners develop ideas for guidelines and products about physical activity.

A few people will watch the group from behind a one-way mirror. We will also record this talk by audiotape. Observers will write down what is said and listen to the tapes. We do this to help us write a report. We will not let anyone outside this project read or listen to anything that was taped. All that you say will be kept private. We will not put your name in the report or on the tapes. The tapes will be kept in a locked cabinet. The tapes will be erased by [date – 1 year after focus groups].

There will be no risk to you. You do not have to answer any question you don’t want to answer. You may stop at any time.

This project is sponsored by the Centers for Disease Control and Prevention. The Academy for Educational Development is helping to do this research. If you have any questions about this project, please call Lori Schmoyer at (770) 488-5227.

If you have questions about your rights or think you have been harmed, please call someone from the Human Research Helpline at 1-800-584-8814. Leave a message with your name and phone number, and someone will call you back as soon as possible.

I can provide you both of these phone numbers if you have any questions.

We thank you for your time.

Participant Consent

By signing below I show that I heard the About this Project statement and know my rights as a participant. I agree to join today’s group. I know that in the group we will talk about physical activity and guidelines. I agree to be audiotaped and observed. I know that only the people working on this project will be able to listen to the tapes. I understand that neither my name nor identity will be used in any report or other products that may come out of this project.

If you are prepared to sign this consent, please provide your signature, printed name, and today’s date here:

Signature: ________________________________________________________

Name (Please print): ________________________________________________

Date: _________________________