Adult Consent Form

Appendix E1

Consent Form for Adults

Adult Consent Form

Project: “Formative Research of Adults’ and Childrens’ views Related to Promotion of Healthy Food Choices”

Phases 1, 2 or 3

We have asked you to take part in a group discussion for a research project with other parents. It will be about ways to speak to parents and children about food. Your ideas will help us design and send out messages to help families eat healthy foods.

The discussion will take about 2 hours. A trained moderator will lead it. First you will get to know each other a little bit. Then you will be asked for ideas about some messages for a program. At the end of the discussion, you will receive $50.

Your being in this study does not mean that you or your family have poor nutrition. We do not know of any risks to your being part of this study. You will be sharing your thoughts and ideas. You may find the experience fun.

You do not have to take part in the group if you do not want to. If you take part, you do not have to answer any questions you do not want to answer. You can leave the group at any time.

We will audiotape and videotape this group discussion. Some researchers will watch the group. Others may watch or listen to the tapes later. We will transcribe the tapes after the group is over. We do this to make sure that our written report of the discussion is accurate.

All that you say will be kept private as allowed by law. Focus group response data will be collected by AED and their subcontractor, Alan Newman Research (ANR). Transcripts derived from the focus groups will be read and analyzed by only AED and ANR research staff. The only personal identifiers that will be obtained by AED and ANR and are the participants’ names for scheduling purposes, and this information will not be linked to the response data or shared with CDC. In addition, results will be aggregated so that it will not be possible for an individual to be identified. First names only will be used during the group discussion, and only first name, without any identifying information, will be included in transcripts.

We do not plan to include your name in the report or on the tapes. The tapes will be kept in a locked cabinet. The tapes will be erased by (insert date 12 months from date of focus group). No one outside of this project will be able to listen to or watch the tapes.

This research is sponsored by the Centers for Disease Control and Prevention. The moderator who leads the discussion is from a company called Alan Newman Research. The Academy for Educational Development is also helping to do this research. If you have any questions about this study, please call Ms. Reba Griffith at 770-488-5548.

If you have questions about your rights as a participant in this research study or think you have been harmed, please call the CDC Deputy Associate Director for Science at 1-800-584-8814, leave a message including your name and phone number, and someone will call you back as soon as possible.

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Adult Consent Form

I agree to take part in this group discussion. I have read the Project Information. I understand that the group will talk about what foods families eat. I also agree to be audio- and videotaped and observed.

Participant Signature: __________________________________________

Participant Name (please print): ___________________________________________

Date: ___________