Attachment D
Sample Informed Consent to Participate in a Study
Introduction
(enter contractor’s name) is conducting focus group discussions on behalf of the Centers for Disease Control and Prevention, also called CDC. This project is being sponsored by CDC. The objective of the study is (enter objective).
You have been invited to participate in a (focus group/survey). It will last (enter time). Before you agree to participate, please review and consider the information listed below.
Participation in this interview is completely voluntary.
Any questions you have about this study will be answered before the interview begins.
The discussion will be audio-taped and a report will be prepared for the CDC.
Your name will not be used in the report about the interview and no quotes will be linked to you.
The interview may be observed by project staff from (enter contractor’s name) and CDC.
We ask you to avoid using your last name during the interview.
You may choose not to answer questions that you do not want to answer.
You may choose to leave the interview at any time for any reason.
Thank you for your participation in this study..
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.
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 (enter number), 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 (enter point of contact). 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
| File Type | application/msword |
| File Title | Informed Consent Form |
| Author | T. Abend |
| Last Modified By | CDC User |
| File Modified | 2013-06-06 |
| File Created | 2013-05-29 |