DG FG Consent FINAL 2010-01-21

Form Approved

OMB No. 0990-0281

Exp. Date XX/XX/XX12

Dietary Guidelines Focus Group Consent Form

[NOTE TO FOCUS GROUP FACILITY STAFF: Please read aloud to participants the “About This Project” and “Participant Consent” statements below. Then ask each participant to sign, print their name, and write today’s date on the form.]

Your Permission for the Discussion Group

About This Project

We have asked you to join a group of 10 people to talk about a few topics. The talk will last about 2 hours. A trained person will lead it. You will help the government develop some ideas into health promotion materials to help people make better choices about the food they eat.

A few people will watch the group from behind a one-way mirror. We will also video-record and audio-record this discussion. Observers will write down what is said and view and listen to the recordings. We do this to help us write a report. We will not let anyone outside this project read, view or listen to anything that was recorded or written down. All that you say will be kept private. We will not put your name in the report or on the recordings. The recordings will be kept in a password-protected computer file. The recordings will be deleted by October 31, 2011.

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

This project is sponsored by the US Department of Health and Human Services. The American Institutes for Research is helping with these discussion groups and the project. If you have any questions about this project, please call Margarita Hurtado at (301) 592-2215.

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 write down both of these phone numbers for you so you can call if you have any questions.

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 some ideas about how to make healthy choices about food. I agree to be video-taped, audio-taped and observed. I know that only the people working on this project will be able to view or 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 decide to sign this form, it means that you agree to be part of the study and to participate in this discussion group. If you do not understand any part of what I have said, be sure to ask me. Do not sign until you have answers to your questions.

If you choose to take part in this study, please sign, print your name, and write today’s date below:

Sign Here: ____________________________________________

Print Name:___________________________________________

Today’s Date: _______________

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DG FGs- Consent v1 AIR 12/15/09