Attachment 3 - CONSENT FORM MOB-CDC 1-27-09

Important Confidentiality Notice

Information collected by the A Matter of Balance program is used by MaineHealth’s Partnership for Healthy Aging and the Matter of Balance Master Trainer Sites to improve the program. The information may also be shared with researchers working with A Matter of Balance.

Researchers will keep information about you confidential. Electronic information will be kept in secure computer files and paper information will be kept in a locked file drawer.

I give my permission for my information to be given to researchers assisting with program evaluation and improvement.

Signature: _________________________________________________

Date: ____/____/____

Supplemental Informed Consent Solicitation

Researchers at the Centers for Disease Control and Prevention (CDC) want to contact some program participants to ask additional questions about their experiences in the A Matter of Balance program.

Please sign below and write your phone number if you are willing to be contacted.

I give permission for CDC researchers to call me.

Printed name:_______________________________________________

Signature: _________________________________________________

Date: ____/____/____ Phone number: ( ) _______-____________