Focus Groups Minor Informed Verbal Assent

Evaluation of health communication messages for

Infertility Prevention Campaign

0920-09XX

Attachment 4A

Minor Informed Verbal Assent

2/3/2021

Minor Informed Verbal Assent

Infertility Prevention Campaign

Reading level: 7

The Academy for Educational Development (AED) and the Centers for Disease Control and Prevention (CDC), invite you to be in a research study. The purpose of this research is to help CDC learn how to talk to girls/women your age about things they can do now to protect their health and future fertility. You will be asked to give your opinions on how information is presented and whether it is easy to understand. Please feel free to ask questions as I explain the study.

If you agree to participate, you will join a discussion with up to 8 other girls your age and a researcher. The discussion will be used to help CDC prepare messages and materials for people your age about preventing illness or infertility from STDs.

The information you give us will be kept private. Your name will not appear in the report. All notes and tapes will be kept in a locked cabinet. No one outside this project will have access to them. Tapes will be deleted after the study. We will not share your information with your parents/guardians or anyone else.

The focus group poses no risks to you. If you begin to feel uncomfortable at any time, you can refuse to answer questions or leave the discussion. No one is trying to sell you anything.

Your participation is voluntary. If you agree to participate, you will receive a check for $75 at the end of the focus group.

If you have any questions about the topics we’ll be discussing, you can call the CDC at 1-800-CDC-INFO (232-4636). Leave a message with your name and phone number, and someone will call you back as soon as possible. Do you have any questions at this point?

Minor Verbal Assent

I will read you a list of statements about this research. After, I will ask you for your full name, and whether you agree to take part in the focus group. This information will be kept in a secure place. It will not be connected to your responses during the focus group. No one else at the focus group will know your full name and contact information.

I understand and agree that:

• During the focus group, we will cover health topics, including infertility prevention

• I may refuse to participate or leave the focus group at any time

• I will be asked to respond to materials that will require reading at a 7^th grade level

• My name and opinions will be kept confidential. Only my first name will be used during the focus group, or I may choose to use a fake name

• The information I provide will not be shared with parents/guardians or anyone outside the study

• The discussion will be audio taped and researchers may observe behind a one-way mirror

• The discussion will only be used for research

• No one will try to sell me anything

• I will receive $75 for participating

• I have asked any questions I have

Please state your name: ____________________________________________

Do you, _________________________________ (Name), agree to participate in a 2 hour focus group discussing teen health issues?

[Circle response] Yes No

[Record date] ___________________________

(Read Invitation)

Invitation

Thank you for answering my questions. I would like to tell you a little more about the discussion group. The group will meet on [Date] at (5:30pm or 7:30pm) at our office in [CITY, GIVE ADDRESS]. The group will consist of 8 other young women, such as yourself, and a moderator. It will meet for about 2 hours. You will receive $75 for participating.

So that we can start and end on time, please plan to arrive about 15 minutes early to pick up your nametag and to have some refreshments. We are counting on your participation, so please be sure to contact us as soon as possible if something comes up and you can't attend. (GIVE PHONE NUMBER).

Also, do you wear reading glasses or use a hearing aid?

If so, please remember to bring them. Some activities will involve reading and listening.

NAME______________________________

PLEASE CHECK ____ MR. ____ MRS. ____ MISS ____ MS.

PHONE________________________________ TYPE ______________

ALTERNATE PHONE______________________ TYPE ______________

ADDRESS ____________________________________________

____________________________________________

____________________________________________

Has hearing aid  (check here)

Wears glasses  (check here)

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