Consumer Focus Groups Relating to Prepaid Products Rulemaking and Model Form Development

Informed Consent
As part of a research study for the Consumer Financial Protection Bureau, a Federal government agency,
ICF International is conducting this focus group to learn more about how you make financial decisions.
Before you decide to participate in the focus group, here are some things you should know:


Your participation is totally voluntary.



You can choose not to answer any questions you do not want to answer.



We will not disclose personal information about you, except as described in this form, unless legally
authorized or required by law to do so.



Your name will not be used in any written reports or presentations for this project.



We will take notes during the focus group for our research purposes.



Staff from the Consumer Financial Protection Bureau and ICF International will observe the focus
group from another room.



This focus group will be audio and video recorded. The audio and video recordings may be shared
with the employees of the Consumer Financial Protection Bureau and authorized contractors who
have a need for the information for official business purposes. All such persons are under obligation
to protect the privacy of the information in the recordings.



You will receive an incentive of $75 to compensate you for your time.



You may discontinue participation at any time, either by leaving the focus group or not answering a
question, without penalty or loss of benefits.



Any questions you have about this focus group and the study will be answered before we begin the
focus group. Contact information is provided below for any questions that arise after your
participation.



The focus group will last approximately 90 minutes.



We will provide reasonable accommodations for any disabled persons; if you require
accommodations, please let us know.



This research study has been approved by the US Government Office of Management and Budget
and has been assigned OMB Control Number 3170-0022.

Contact information: If you have any questions or concerns about your participation in this focus group
or our research study, please contact the Project Manager, Michael Long, at 301-572-0945.
By signing this document you understand the above and agree to participate in this focus group.
Print your name:

_________________________

Date:

_________________________

Signature:

_________________________

Witness: _________________________