Consent Form

Evaluation of Health COmmunication Materials

of the Office of WOmen’s Health

INFORMED CONSENT FORM

The purpose of this research is to gather information that will enable the Office of Women’s Health (OWH) to improve its Women’s Health publications. By signing below, I am expressing my willingness to participate in a discussion group that will last approximately one-and-a-half hours. I understand that I will be asked my opinions about the format and content of a specific health communication material. The questions asked during this group will facilitate discussion around how I used the material and how effective the material was in positively impacting changes in my knowledge, attitude and behavior around health issues.

I understand that my responses will be treated in a private manner to the extent allowed by law. I further understand that all demographic surveys will be kept under lock and key. Identifying information will be kept separate from data. When data is no longer needed, it will be destroyed.

While I may derive some personal benefit from participating in the group, I recognize that this study is not designed to help me personally, but to help the investigators learn more about the health publications. I am free to ask questions or withdraw from participation at any time and without penalty.

I am over 18 years of age:		YES		NO
I have participated in another OWH survey in the past 6 months:		YES		NO

NAME OF PARTICIPANT:
SIGNATURE:
DATE:

Investigator’s Contact Information
Name:	Michele DeBarthe Sadler, Ph.D., MPH	Name:	Elizabeth Fassett, MS, CHES
	Shattuck & Associates		Hager Sharp
Phone:	410-715-0054	Phone:	202-842-3600