Informed Consent Baltimore

Form Approved

OMB No. 0920-0919

Exp. Date 01/31/2015

Attachment 12 -CONSENT FORM

ASSURANCE OF CONFIDENTIALITY 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 treated in a secure manner. 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 given $75.00 if you take part in this 90-minute focus group. You will receive this incentive 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: _______________________________

The public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-0919).