Informed Consent - English

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/XXXX

Informed Consent to Participate in a Study

Introduction

Battelle Centers for Public Health Research and Evaluation, a non-profit organization, is conducting focus group discussions on behalf of the Centers for Disease Control and Prevention, also called CDC. This project is being sponsored by the Centers for Disease Control and Prevention, also called CDC.

The objective of the study is to help CDC understand women’s opinions and practices related to their health. You have been invited to participate in a focus group discussion with other women. It will last one hour and a half. Before you agree to participate, please review and consider the information listed below.

1. Participation in this interview is completely voluntary.

2. Any questions you have about this study will be answered before the interview begins.

3. The discussion will be audio taped and a report will be prepared for the CDC.

4. Your name will not be used in the report about the interview and no quotes will be linked to you.

5. The interview may be observed by project staff from Battelle and CDC.

6. We ask you to avoid using your last name during the interview.

7. You may choose not to answer questions that you do not want to answer.

8. You may choose to leave the interview at any time for any reason.

9. Thank you for your participation in this study.

10. Are there any risks to my being in this project?

The risks and discomforts associated with your participation are minimal and limited to those that may occur in a conversation about health problems. This project only involves your opinions about what you do to stay healthy.

11. What are the benefits to being part of this project?

There are no direct benefits to you. The information from this study will provide you with some health information and may be used to develop future programs that help women like you improve their health.

For more information about this study

If you have questions about your rights as a research participant in this study, please call 1-800-584-8814, leave a message including your name and phone number, and your call will be returned as soon as possible. For specific information about the study, you may call Carlyn Orians at Battelle at 206-528-3320. You will receive a copy of this form.

Your signature below indicates that you were told about the study and agree to participate.

The content of this consent form has been explained to me. I have had the chance to ask questions about this project and understand that I can ask questions at any time. I have received a copy of this form.

Signature Date

Witness

The public reporting burden of this collection of information is estimated to average 6 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 (0920-11DE)