A9 Triad Consent Form_02

ATTACHMENT 9:

TRIAD CONSENT FORM

(note: both homeowners and generator owners will use the same form)

Introduction: Thank you for agreeing to be in our discussion about household safety. Through discussions with you and others, we hope to improve materials being developed on household safety. RTI International, a non-profit research company, is doing this project. The Centers for Disease Control and Prevention (CDC) is the sponsor. We will be conducting discussions with approximately 48 other people. Process: You will be in a group for about 2 hours. The group will be audio taped. There will be some people from RTI and the CDC behind the mirror observing so that they can hear what you and others have to say. During the discussion, you will be asked question about some information and materials being developed on home safety. 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. You will be provided $75 to help reimburse any personal expenses. Risks and Right to Refuse: During our session, you may be asked your opinion on materials. There is always a 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 identity private, but we cannot be sure that this information will be kept private. Benefits: Your input will help the CDC to develop education materials and improve home safety. If you have any questions on home 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 your 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.

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Signature Date

(Reading level on the Fleish-Kincaid scale: 8.0)