Consent Form

App B_Consent_5 21 2014.doc

Focus Group Testing to Effectively Plan and Tailor Cancer Prevention and Control Communication Campaigns--New

Consent Form

OMB: 0920-0800

Document [doc]
Download: doc | pdf

Focus Groups Assessing the Uptake and Effectiveness of Inside Knowledge: Get the Facts About Gynecologic Cancer Campaign Materials


About the Project


You are invited to participate in a focus group discussion with others from the general public (or providers for the provider focus group). Your participation will help the public and health care providers to better understand gynecologic cancers. The talk will last about 2 hours. A trained leader will lead the discussion. The results will help public health planners design and refine materials for the Inside Knowledge: Get the Facts About Gynecologic Cancer campaign. Information from today’s focus group might be shared with the public through a journal publication.


We will transcribe information from this talk and record answers to questions. Individual names will not be included in the written notes. We do not plan to allow anyone outside this project to 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 the information collected from the focus group discussion available to the project team during analysis and no names will be included on this information. The information will be kept in a locked cabinet. We plan to destroy all the information following analysis.


We do not foresee any risks to you from participating in this focus group discussion. 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 Sherri Stewart at 770-488-4616.


If you have questions about your rights as a participant in this project or think you have been harmed, please call CDC’s Division of Cancer Prevention and Control at 770-488-3943. 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 observed and have my responses noted. I understand that only the people working on this project will be given access to the information collected. 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: ___________________________

File Typeapplication/msword
File TitleProject Background and Purpose
AuthorPNI
Last Modified BySherri Stewart
File Modified2014-05-21
File Created2014-05-21

© 2024 OMB.report | Privacy Policy