0920-0572 ATSDR-Message-Testing_Attachment-8_Consent-Form

CDC and ATSDR Health Message Testing System

ATSDR-Message-Testing_Attachment-8_Consent-Form

Agency for Toxic Substances and Disease Registry Task Order 15: Message Testing

OMB: 0920-0572

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Form Approved

OMB No. 0920-0572

Exp. Date: 2/28/2015



ATSDR Task Order 15 Message Testing

Attachment 8

Consent Form1

___________________________________________________


I, _________________________________________, agree to take part in this focus group.


I understand that I do not have to be in this study. I can leave at any time without penalty. I can agree to be in the study and then change my mind later.


I allow the Centers for Disease Control and Prevention (CDC) to use the information from this study.1 I understand that the information is for research only, and that my name will not be shared with anyone else.


I agree to ask questions about the study if I don't understand something. If I have questions after the study is over, I can contact Perrie Briskin at [email protected] or at 413-582-0425.


Audio Recording


I understand that I will be audio recorded during this study. I understand the recording will not be transcribed. I allow CDC to use the recording to help them write a report without my name for research purposes. I understand that the recording will be destroyed and my name will not be used for any other purpose.


Summary


I have read and understood this consent form. I understand that I will get a copy of this form.


Print Name:         _________________________________________


Signature:           _________________________________________


Date:                   _________________________________________


1 The ATSDR is authorized to collect this information by [CERLA and SARA].


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorSandra Williams Hilfiker
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File Created2021-01-31

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