Attachment 6 - Consent

ATTACHMENT 6

Informed Consent

FOCUS GROUP DISCUSSION CONSENT FORM

Study Title: Audience Analysis for Environmental Health Issues

Sponsor/Project Officer Centers for Disease Control and Prevention

Address: National Center for Environmental Health

Agency for Toxic Substance and Disease Registry

Office of Communication

Centers for Disease Control and Prevention

2920 Brandywine Road, Room 3000

Atlanta, GA 30341-5539

PURPOSE OF THE RESEARCH STUDY

This study is focused on the public’s attitudes and behaviors around climate change. Findings from this research will inform the development of communication materials to increase the public’s awareness, knowledge and preparation for climate change health effects.

INFORMATION ABOUT THE STUDY

If you agree to participate in the research you will participate in one focus group. During this group, you will be asked about your opinions and beliefs about climate change and its impact on human health. You will also be asked your thoughts on possible concepts and messaging for increasing the public awareness and preparing for health effects associated with climate change. The focus group will last about 2 hours. Focus group conversations will be audiotaped and notes will be taken to record your responses. Only first names will be used to protect your privacy.

YOUR ROLE IN THE STUDY

Participating in a research study can be an inconvenience to your daily life. Please consider the study time commitments and responsibilities as a research subject when you are deciding to participate. Your responsibilities as a study subject include the following:

• Come to the study site for the focus groups at the planned time.

• Provide truthful information about what you think about the usefulness of the concepts and messages discussed.

RISKS OF THE STUDY

There are no known physical or psychological risks from taking part in this study.

POTENTIAL BENEFITS OF PARTICIPATING IN THE STUDY

You may receive no direct benefit from participation in this research. The results of this research will help to identify the most valuable information and optimal strategies for communicating with the public about climate change health effects.

ALTERNATIVE TO PARTICIPATING IN THE STUDY

Since this study does not benefit you directly, your alternative is not to take part.

YOUR PAYMENT FOR BEING IN THE STUDY

You will receive $75 for your participation in the focus group. You will be paid at the end of the focus group session.

CONFIDENTIALITY

As part of this study, the study staff may record personal information about you that contains your name and other personal identifiers. All records will be stored in a locked file cabinet, accessible only to project staff. Except for this form, all records we have that contain your name, telephone number, or other written information that could identify you will be destroyed at the end of the study, which is currently July, 2010. We will keep this form for one year after this study is completed, and will then destroy it. Your comments during the focus group will be audio-taped and transcribed for use by the research team in developing a report. Transcripts of focus groups will only record your first name. Your first name or other personal facts that would identify you will not be used when we discuss, or write about, this study. The audio-tapes will be stored in a locked file cabinet, accessible only to project staff. The recording will be destroyed at the end of the study, which is currently July, 2010.

getting answers to your questions about the study

If you have questions about this research, contact the Westat Project Director, Simani Price at (301) 610-5536.

VOLUNTARY participation

Your participation is voluntary and you may withdraw your consent and your participation in this study at any time without penalty or loss of benefits to which you are otherwise entitled.

STATEMENT of consent

I have read this form and its contents were explained. I agree to be in this research study for the purposes listed above. All of my questions were answered to my satisfaction. I will receive a signed and dated copy of this form for my records.

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Signature of Research Subject Date

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Printed Name of Research Subject