Attachment C
Authorization and Release of Information
OMB No. 0930-0196
Expiration Date: 09/30/16
Public Burden Statement: 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. The OMB control number for this project is 0930-0196. Public reporting burden for this collection of information is estimated to average 90 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 15E57-B, Rockville, MD 20857.
Authorization and Release
The undersigned hereby authorizes the U.S. Department of Health and Human Services (DHHS), Substance Abuse and Mental Health Services Administration (SAMHSA) to use the information, feedback, and opinions I provided through a focus group in the development and editing of concepts for Public Service Announcements (PSAs) and in their production and post-productions stages.
Procedures: If you participate in this study, you will be in a group of approximately 8 other individuals. There will be a facilitator who will ask questions and facilitate the discussion, and a note taker to write down the ideas expressed within the group. We will also be recording the session to help clarify the information written down by the note takers, should there be any questions in summarizing the results. If you volunteer to participate in this focus group, you will be asked some questions relating your opinions, suggestions and concerns to make the PSA concept messages more relevant, understandable, and appealing. No personal information will be included in the notes; we are using first names only during the session.
Your participation is completely voluntary. You may withdraw from this study at any time without penalty.
Benefits and Risks: Your participation may benefit you and other individuals that are dealing with IV drug use and their families. No risk greater than those experienced in ordinary conversation are anticipated. Everyone will be asked to respect the privacy of the other group members. All participants will be asked not to disclose anything said within the context of the discussion, but it is important to understand that other people in the group with you may not keep all information private.
Be advised that these PSAs will be in the public domain and may be reproduced in their entirety or excerpt pieces in official agency future publications without further permission.
Consent:
By signing below, you are indicating that you fully understand the above information and agree to participate in this focus group.
Participant's signature: _______________________________________________________
Printed name: ______________________________________________________________
Date: ______________________________________________________________________
If you have any questions or concerns about this study, please contact Elaine Rahbar at 240-485-1700.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Luz Amparo Pinzon |
| File Modified | 0000-00-00 |
| File Created | 2021-01-29 |