Consent

Health Provider Formative Focus Group Testing for the

Inside Knowledge: Get the Facts About Gynecologic Cancer Campaign

Consent to Participate in Discussion Groups

About the Project

The Centers for Disease Control and Prevention (CDC) is developing a program for women, age 40 and up, and their health care providers about gynecologic health. To help assure that the program is valuable to providers in diverse specialties, CDC would like to hear from you about your practices, and also get your input about several things. Ultimately, the results will be used to develop gynecologic cancer materials designed for health care providers and their patients.

These groups will be conducted over the telephone in a conference call format OR in-person with eight health care providers participating in each group. A trained leader will lead the discussion. Each group discussion will take approximately 90 minutes. You will receive $200 as a token of appreciation.

We will audio record this talk. Members of the project team will listen to the tapes and write down what is said. Individual names will not be included in the written notes. We do not plan to allow anyone outside this project to listen or read anything that is recorded. All that you say will be kept private to the extent permitted by law. Your name will not be used in any reports or publications resulting from the focus group discussion. We will make transcripts of the focus group discussion and we will delete your name from the transcripts. The tapes will be kept in a locked cabinet. We plan to erase the tapes by (insert date 12 months from date of focus group).

We do not foresee any risks to you from participating in this study. Your participation is voluntary and you do not have to answer any questions or discuss any issues that you do not want to discuss. You may stop participating at any time.

This project is sponsored by the Centers for Disease Control and Prevention. If you have any questions about this project, please call Cynthia A. Gelb at 770-488-4708.

If you have questions about your rights as a participant in this project or think you have been harmed, please call 1-800-584-8814. Leave a message with your name and phone number, and someone will call you back as soon as possible.

We thank you for your time.

Participant Consent Form

My signature verifies that I have read the About the Project and understand my rights as a participant. I agree to participate in today’s discussion. I understand that the group will discuss gynecologic cancers. I agree to be audio-taped. I understand that only the people working on this project will be given access to the audio-tape and transcription. I understand that CDC will not use my name or any other identifying characteristic in any report or other products that may result from this project.

Signature: ________________________________________________________

Name (Please print): ________________________________________________

Date: ___________________________