Att C3 - Consent for Community Reps

Developing, Marketing, and evaluatIon of eagle books and youth eagle books for american indians and alaska natives

INFORMED CONSENT (COMMUNITY HEALTH REPRESENTATIVE)

PURPOSE OF THE PROJECT

We have asked you to take part in an interview to learn more about diabetes prevention work in your community. We would like to find out what you may know about the Eagle Books (a group of children’s books about exercise, healthy eating, and how to prevent diabetes) and the Diabetes Education in Tribal Schools curriculum (or DETS). We would also like to hear what you think about these materials and how they have or can help local efforts to prevent diabetes. We want to talk to you because you work in diabetes education in tribal communities. The Eagle Books and DETS have been developed for American Indian children.

Taking part in this interview does not mean that you are not healthy or that you have diabetes. We want to find out what local health professionals think about the Eagle Books and DETS and how they can help local diabetes prevention work.

The Native Diabetes Wellness Program at the Centers for Disease Control and Prevention (CDC) is in charge of this project. Part of CDC’s job is to develop programs to help people stay healthy and safe. Westat is a company that has been hired to help CDC with this project.

PROCEDURES

• A trained interviewer from CDC or Westat will lead the interview.

• The interview will last about an hour.

• We will not ask you to talk about your personal health. We will ask what you think about the Eagle Books, DETS, and what can be done to prevent diabetes in your community.

• We will answer any questions you have before we start.

• You do not have to answer any questions you do not want to.

• The interviewer will take notes. They will not write your name in the notes. Later, other people working on this project may see the notes because they could not be here in person. Only people working on this project will be allowed to see the notes.

RISK AND BENEFITS

There should not be any risks to you of any kind because you took part in this interview. There are no direct benefits to you for taking part in this interview. What you tell us will help us see if the Eagle Books and DETS are meeting the needs of American Indian children and how they can help in local diabetes prevention efforts.

COMPENSATION

There is no cost to you for taking part in this interview.

CONFIDENTIALITY (PRIVACY)

• Everything you say will be kept private, as allowed by law. We will not use your name in anything we write about this interview.

• Only people working on this project will be able to see the notes. All notes will be kept in a safe and private place.

RIGHT TO REFUSE OR LEAVE

• You can choose to take part in this interview or not. It is voluntary. You do not have to answer any questions you do not want to.

• You can leave the interview at any time.

PERSONS TO CONTACT

If you have any questions about this project, you can call Dr. Lemyra DeBruyn (the CDC person in charge of this project) at 1-505-232-9906. If you have any questions about your rights as a person taking part in this interview or if you feel you have been hurt by taking part, you can call the CDC Deputy Associate Director for Science at 1-800-585-8814. Leave a message and someone will call back as soon as they can. In your message, please say the CDC project number__________________.

CONSENT

I agree to take part in this interview. I have read this form and I was able to ask questions. I feel that all of my questions were answered. I know that we will talk about the Eagle Books, DETS, and local diabetes prevention work. I know that someone from CDC or Westat will lead the interview and take notes. I know that only people from this project will be able to read the notes. I know I can leave the interview at any time. I am at least 18 years old. I have been given a copy of this form.

Your Signature: _____________________________________________________

Your Name (Please Print): ___________________________________________

Date: ______________________________________________________________

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