Consent

Appendix D: Participant Consent Form

Tailoring Gynecologic Cancer Education for Health Care Providers

About the Project

You are invited to participate in a focus group discussion with up to 20 participants. Your participation will help public health planners understand what health care providers think about gynecologic cancers. The discussion will last about 1 hour. A trained leader will lead the discussion. The results will help public health planners design educational materials for medical professionals. Combined results from today’s focus group might be shared with the public through a journal publication.

We will audio record this talk. Members of the project team will listen to the tapes and write down what is said. Individual names will not be included in the written notes. We do not plan to allow anyone outside this project to listen or read anything that is recorded. All that you say will be kept secure to the extent permitted by law. Your name will not be used in any reports or publications resulting from the focus group discussion. We will make transcripts of the focus group discussion and we will delete your name from the transcripts. The DVDs will be kept in a locked cabinet. We plan to destroy the DVDs by June 2015.

We do not foresee any risks to you from participating in this study. Your participation is voluntary and you do not have to answer any questions or discuss any issues that you do not want to discuss. You may stop participating at any time.

This project is sponsored by the Centers for Disease Control and Prevention. If you have any questions about this project, please call Katrina Trivers at 770-488-1086.

If you have questions about your rights as a participant in this project or think you have been harmed, please call 770-488-394. Leave a message with your name and phone number, and someone will call you back as soon as possible.

We thank you for your time.

My signature verifies that I have read the About the Project and understand my rights as a participant. I agree to participate in today’s discussion. I understand that the group will discuss gynecologic cancers. I agree to be audio-taped and observed. I understand that only the people working on this project will be given access to the audio-tape and transcription. I understand that CDC will not use my name or any other identifying characteristic in any report or other products that may result from this project.

Signature: ________________________________________________________

Name (Please print): ________________________________________________

Date: ___________________________