A7 Homeowners Consent Form_02

ATTACHMENT 7:

HOME APPLIANCE OWNERS CONSENT FORM

Introduction: Thank you for agreeing to be in our discussion about generator safety. Through such discussions, we hope to learn the information needs of people related to generator safety. RTI International, a non-profit research company, is conducting this project. The Centers for Disease Control and Prevention (CDC) is the sponsor. We will be conducting discussions with approximately 24 other people. Process: You will participate in a focus group for about 2 hours. The group will be audio taped. There will be some people from RTI and CDC behind the mirror observing so that they can hear what you and others have to say. During the group, you will be asked questions about the health risks of generators as well as ways to better inform people about these risks. What you say during the group will be kept private. Only first names will be used during the group. Your name will not be used in any reports. You will not be called again as a result of your being in the group. At the end, we’ll ask you to complete a brief questionnaire. You will be provided $75 to help reimburse any personal expenses. Risks and Right to Refuse: During our session, you may be asked about your knowledge of portable generators and their safety. There is chance that something we ask can make you uneasy.

You do not have to answer any questions or share any information with others in the group if you do not want. Being in this group is your choice. You can refuse to be in the group or drop out at any time. We will ask everyone in the group to keep your identify private, but we cannot be sure that this information will be kept private. Benefits: Your comments will help CDC develop education materials and improve generator safety. If you have any questions on generator safety at the conclusion of our discussion, we will have an expert available to help answer those questions. Persons to Contact: If you have questions before, during, or after the focus group, you may call Dr. Jon Poehlman at (800) 334-8571 ext. 7068 (a toll-free number). If you have any questions about your rights as a participant, you can call RTI’s Office of Research Protection at 1-866-214-2043 (a toll-free number). Your Consent: A copy of this consent form will be given to you. If you agree to be a part of our session, please sign below.

I have been given a chance to read this form and to ask questions. I agree to be a part of the project.

________________________________ _________________________________

Signature Date