Healthy Weight Collaborative

Mathematica Policy Research

HEALTHY WEIGHT COLLABORATIVE INTERVIEW CONSENT FORM

Introduction/Purpose

You are being asked to take part in the U.S. Department of Health and Human Services (HHS) evaluation of the Healthy Weight Collaborative. Results from the evaluation will inform policymakers and program administrators on how to design and implement community-based learning collaboratives. By taking part, you will bring an important perspective on the Healthy Weight Collaborative project, including how it can be improved. Your participation is important and will help us to learn more about the functioning of the HWC.

Interview Procedure

We are asking you to take part in an interview, in which we will ask questions about your experiences with the Healthy Weight Collaborative. The interview will take about an hour and a half. We will be taking written notes of your answers. The interview will be audio recorded with your permission to fill in anything we missed in our written notes. You can still participate if you do not agree to have the interview recorded, please let me know. There are no “right” or “wrong” answers; we are only interested in learning about your experiences and opinions. You may choose not to answer any questions that I ask, and you may end the interview at any time.

Benefits

You will not benefit directly from this study.

Risks

There is no known risk to you for participating in the interview, other than the possible risk of the loss of confidentiality, which is addressed below.

Confidentiality

To protect your privacy, we will keep confidential all information you give us as we develop our notes and evaluation reports. We will not identify you personally in any report or publication of this study. Recordings from the interview will be stored in a password-protected folder that can only be accessed by the study’s research team. The interview notes and summaries will be locked in a cabinet in the evaluation team’s office. While project records can be opened by court order or produced in response to a subpoena or a request for production of documents, we will keep any records that we produce private to the full extent of the law. All documents and interview recordings will be destroyed at the end of the project.

Participation Is Voluntary

Your participation in the interview is entirely voluntary. You may withdraw your consent or stop taking part at any time, without penalty. You may refuse to answer any question you do not wish to answer during the interview. The investigator or New England IRB can also stop your participation at any time.

Questions

If you have any questions about taking part in the interview you can contact Margaret Hargreaves at Mathematica Policy Research, 955 Massachusetts Ave., Suite 801, Cambridge, MA, 02139, (617-301-8994). If you have questions about your rights as a participant, you can contact New England Institutional Review Board (NEIRB), 1-800-232-9570.

If you agree to participate and to be audio-recorded, please sign below and pass the signed document to me now.

_______________________________ _________________________________

Your name (printed) Your signature

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