Innovator - Consent form

Form Approved

OMB No. 0920-0798

Exp. Date: 01/31/2011

Attachment 11

Consent to Participate in Innovator Interview

Purpose

You are being asked to participate in a research study. RTI International is conducting a series of telephone interviews sponsored by the Centers for Disease Control and Prevention (CDC). The purpose of these interviews is to talk to innovators and experts in the field about preconception care. About 18 people total will take part in the discussions.

Procedures

If you agree to participate, you will take part in a telephone interview for about 60 minutes.

An experienced interviewer from RTI will moderate the discussion. Another member of our project team will take notes during the interview. The discussion will also be audio recorded. The recordings will help us get everything you have to say. It is possible that someone from the CDC would be listening to the discussion so they can better understand your views and opinions. If they are listening, we will let you know. They also will not participate in any way during the discussion.

Possible Risks or Discomforts

We do not expect any risks to you from participating in the interview.

Benefits

There are no direct benefits to you from answering the questions except the satisfaction of helping CDC better understand issues relating to preconception health so that they may develop better health information for women.

Incentive for Participation

You will receive $75.00 for your time and effort to participate in the interview.

Security of Information

Your answers will be used to write a summary report, but we will not use any real names in the report. Your name will not be given to anyone. The notes and the recordings will be kept in a locked file cabinet in the RTI office and will be destroyed after the project is completed.

Future Contacts

RTI and CDC will not contact you in the future regarding this study.

Your Rights

Your decision to take part in this interview is completely voluntary. You can refuse any activity and you can stop participating at any time. You can refuse to answer any question. If you decide to participate and later change your mind, you will not be contacted again or asked for further information.

Your Questions

If you have any questions about the telephone discussions, you may call Dr. Linda Squiers at RTI at 301-576-8088. If you have any questions about your rights as a focus group participant, you may call RTI’s Office of Research Protection toll-free at 1-866-214-2043.

Public reporting burden of this collection of information is estimated to average 5 minutes, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74,  Atlanta, Georgia 30333; ATTN:  PRA (0920-0798)