Form 1 Focus Group Screener and Consent

Appendix B: Screenshots - Focus group
screener and consent

National Institute of Nursing Research (NINR)
Pediatric Palliative Care Focus Groups Screener
OMB #: 0925-0653
Expiration Date: 03/31/2015
Public reporting burden for 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0653). Do not return the completed
form to this address.
We would like to invite you to participate in an online group discussion. To express our appreciation for assisting us with your insights, we will offer a participant honorarium paid to
you via check if you qualify and complete the 90 minute online session. Participation in this screener will take 10 minutes or less.

1

2

3

4

5

6

b. I understand that all information collected in this focus group is private under the Privacy Act, and will not be
disclosed to anyone but the researchers conducting this study, except as otherwise required by law. All findings will be
reported in aggregate.

consent statement and agree to participate in the focus

7

8

9