Informed Consent

INFORMED CONSENT FORM

FOR VOLUNTEER FOCUS GROUP RESPONDENTS

Please read this form carefully. If you decide to take part in this study by participating in this focus group, you must sign the end of this form.

Westat is conducting research to develop health education materials on deep vein thrombosis and pulmonary embolism. The research will consist of completing a short questionnaire and participating in a 90-minute focus group discussion with up to 8 other individuals. The Centers for Disease Control and Prevention (CDC) is sponsoring this study and Westat, a research firm, is conducting this study. Your input is very important, as it will assist health agencies with creating useful health promotion and education materials.

Your participation in this research is completely voluntary. You can refuse to answer a question or withdraw from the focus group. There are no known risks from taking part in this focus group.

Everything you say in the focus group will be kept secure. The report summarizing the findings will not contain any names or identifying information. Everything shared during the focus group sessions should remain in the session and not shared with anyone outside the group. The focus group will be audiotaped; only staff directly working on the research will have access to the recordings. The audio files will be stored securely and only our research team will have access to them. The audio files will be destroyed at the end of the study.

You will be paid $75.00 if you take part in this 90-minute focus group. You will be paid at the end of the focus group session.

If you have any questions about the study, please ask the person who provided this form to you. If you have any questions about your rights as a participant, please contact Sharon Zack at [email protected] or 301-251-1500.

If you agree to participate in this study, please sign the following statement:

I have read this consent form and understand the proposed project.

I consent to participate in this study.

Participant: ___________________________ ________________________

(Print name) (Signature)

Date: _______________________________