Attachment 10 - Privacy protection agreement for observers

Attachment: 10

APPROVED
OMB # 0920-XXXX____________________
OMB EXP. DATE_____/_____/______

Privacy Protection Agreement for Focus Group Recruiters, Moderators, Note Takers, and Observers

Because of concerns about protecting participant privacy and fostering an atmosphere of respect for the participants, it is important for all persons who are recruiting, moderating, taking notes, or observing focus groups to accept the following requirements:

• Treat all information obtained or collected for this project as private.

• Do not discuss the identity of any focus group participant or what was said by any individual participant with others, with the exception of those who are authorized to have access to the information.

• Do not use the collected information for any purposes other than for your work on this project.

• Maintain all collected information, notes, and materials in your possession in a secure location at all times until they are sent to Mel Miller, Project Director at ICF Macro (240) 747–4750.

• If a computer is used to enter or store collected information, keep that information in password-protected electronic files only and on a computer that has current virus protection software.

• Report the loss of any collected information or materials or the corruption of any computer files containing collected information immediately to Mel Miller at ICF Macro at (240) 747–4850.

• Comply fully with any other data participant protection procedures required for this project.

Your signature below indicates that you understand and accept the above requirements.

Recruiter/Moderator/Note Taker/Observer Name:	_________________________________________
Recruiter/Moderator/Note Taker/Observer Signature:	_________________________________________
Date:	_________________________________________

Witness Name:	________________________________________________
Witness Signature:	________________________________________________
Date:	________________________________________________

Public reporting burden of this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Information Clearance Officer, 1600 Clifton Road N.E., MS D-74, Atlanta, Georgia 30333, ATTN: PRA (0920-XXXX).