Consent for 18-19 year olds

APPROVED
OMB # 0920-0858
OMB EXP. DATE 07/31/2011

Attachment: 9

Informed Consent (Focus Groups)—Young Adults (Ages 18–19)

[Month and year of focus group to be inserted]

ICF Macro is conducting telephone focus groups on behalf of the Centers for Disease Control and Prevention (CDC) and the National Hemophilia Foundation (NHF). You have been invited to participate in a 90-minute focus group with other young adults your age living with hemophilia. This telephone focus group will help us better understand how to best communicate messages on transition issues for young adults aged 18–19 years living with hemophilia.

Before you agree to join in this discussion, please review and consider the conditions listed below:

• Participation in this group discussion is completely voluntary.

• Any questions you have about this study will be answered before the group discussion begins.

• The discussion will be audio taped. The tapes will be used to help the leader of the focus group create a report.

• Project staff from CDC, NHF, and ICF Macro will be on the line listening to the discussion.

• We ask you to use your first name only and avoid using your last name during the focus group.

• The information you give will remain private and your name will not be associated with your answers.

• You may choose not to answer questions that you do not want to answer.

• You may choose to leave the group at any time for any reason.

• The risks to you from participating in this research are minimal, and you will receive no direct benefits, other than $50 for your time and, if one of the first 10 adolescent participants to have qualified, an iTunes gift card valued at $15.

Contact information: If you have any concerns about your participation in this discussion group or have any further questions about the project, contact Mel Miller at ICF Macro, telephone number (240) 747–4750.

Your signature below means that you understand the conditions stated above and agree to participate in this group.

Signature _______________________________ Witness ____________________________________

Date _______________________________________

Public reporting burden of this collection of information is estimated to average 6 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 (0920-0858).