Attach F

Attachment F: Form for consent for expanded use of video and audio recordings

DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

National Institutes of Health

National Cancer Institute

6130 Executive Blvd, MSC 7344

EPN 4005

6130 Executive Blvd

Bethesda, Maryland 20892

OMB #0925-XXXX

Expiration Date: XX/XXXX

Consent for Showing a Recording of the Interview to Others

Purpose

National Cancer Institute staff often presents what we learn from our projects at conferences or scientific meetings. We would like your permission to show the recording of your interview to those who are interested in survey questions. Those people are not working directly on this project. If you agree, we may show the recording at conferences, for students, or for other people who write survey questions. In these cases, the recording is always under the control of NCI staff.

Why do we want to show the recordings?

The recordings show how people react to our survey questions. They show how questions can be hard to understand or hard to answer. They help people write better survey questions. They may also teach other researchers how to test survey questions.

Where will the recordings be shown?

We may show parts of the recording in a small meeting room, a classroom, or a large group at a professional meeting.

What information will be on the recording?

The whole recording could be shown. But it is more likely that a short piece will be shown about a problem with a question. No information about you will be added to the recording. However, your face and/or voice will appear on the recording.

What if I say yes now, but change my mind later?

If you change your mind, or have questions, contact Dr. Gordon Willis by phone at (301) 594-6652, or by mail at 6130 Executive Blvd, MSC 7344, PEN 4005, 6130 Executive Blvd, Bethesda, MD, 20892. You may change your mind at any time. When Dr. Willis receives your request, we will not allow the uses of your recording described on this form.

Please check one of the following boxes:

 I allow NCI staff to show my recording to people at conferences and meetings, to students, and to other people who write survey questions. I understand that my face and voice will appear on the recording. The recording will not be altered. The recording will be in the control of NCI staff. If I change my mind at any time, I will contact Dr. Gordon Willis at NCI

• I do not allow NCHS to use my recording in this way.

______________________________ __________________________ __________

Participant Signature Print name Date