Attachment C - Focus Group Consent Form

ATTACHMENT C

Consent for Participation in Focus Groups

FINAL 2.27.12

Introduction and Purpose:

You have been asked to take part in a focus group as part of a research study. The purpose of the focus group is to hear your thoughts on materials that are being developed. RTI International, a non-profit research company in North Carolina is doing the focus group. The focus group is sponsored by the Agency for Healthcare Research and Quality (AHRQ).

Procedures:

Up to 9 healthcare professionals and a moderator will participate in the focus group. During the focus group, we will ask you to review some draft materials and tell us your thoughts. The focus group will take about 90 minutes.

Study staff will take notes through the one-way mirror.

Risk/Discomforts:

If you feel embarrassed or upset by the things that are talked about during the focus group, you can decline to talk about any topic for any reason. You can stop being in the focus group at any time. It is your right to refuse to answer any questions or stop participating in the focus group at any time.

Benefits:

There is no direct benefit to you for being in this study. However, you may learn more about ways to find information on effective treatments for various conditions and diseases.

Confidentiality:

We will be audio-taping the focus group. Tapes will be kept in a locked cabinet. They will be destroyed at the end of the project. Notes will be made of the tapes. We will only refer to first names in the notes. Your comments will be kept private to the extent allowable by law. The notes will be kept on a password-protected computer. Only authorized project staff will be able to see them. Any forms related to the project that have your name or information that could identify you will be kept in a locked file cabinet. These forms will be destroyed once the project ends.

Also, any information that this local facility already has about you -- because you have been in other projects -- will still be kept there. You may be contacted by them to be involved in other projects in the future. If you have not been contacted by this facility before this project, they will not keep any of your contact information.

Payment:

We will give you $250 for your time, effort and travel expenses.

Right to Refuse or Withdraw:

It is your choice to do the focus group. You can choose not to answer any question. You can stop being in the study at any time.

Persons to Contact:

If you have questions about the focus group or the amount of time to complete this consent form and participate in the focus group, you can call Jennifer Alexander (RTI) at (301) 770-8219 between 9 AM and 5 PM Eastern Standard Time Monday - Friday. If you have questions about your rights as a participant, you can call Wendy Visscher of RTI’s Office of Research Protection toll-free at 1-866-214-2043.

Your Consent:

I have read this consent form. I have had a chance to ask questions and my questions were answered. I was given a copy of this consent form. I agree to be in the focus group.

Signature

Date

Moderator Signature