Key Informant Interview Guide_Consent Form

OMB Control No: 0920-xxxx

Expiration Date: xx/xx/20xx

Attachment G: Key Informant Interview Guide_ Consent Form

Public reporting burden of this collection of information is estimated to average 25 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 CDC/ATSDR Information Collection Review Office; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN:  PRA (0920-xxxx)

Public Health Systems, Mental Health and Community Recovery

Key Informant Interview

CONSENT FORM

The Centers for Disease Control and Prevention (CDC) is sponsoring this study to gather information on preparedness, response, and recovery efforts that occurred during the 2011 “super outbreak” of tornadoes in Alabama and Mississippi. ICF International (ICF) and its subcontractor University of Alabama-Birmingham (UAB) are conducting key informant interviews with State Public Health and Mental Health staff and community members in the areas affected by the disasters. We are asking you to participate in a 60 minute face-to-face interview with a trained interviewer who will ask you to respond to a set of questions about your experiences working with communities around the 2011 tornadoes.

Participation

• Your participation will contribute valuable insights to our project; however, your participation in this interview is completely voluntary. You may discontinue the interview at any time without penalty or consequence. Participation in this interview will not affect any aspect of your job either positively and negatively.

• We would like to get your permission to record this interview to ensure that we accurately capture details that you provide. However, if you do not agree to be recorded, we will not record the interview. If you agree to be recorded, only ICF and UAB employees will be able to use the recording. To protect your privacy, we will keep the notes and recordings in private files and only ICF study staff members will be allowed to use them. All recordings will be destroyed at the end of the evaluation, approximately 3 years from now. Do I have your permission to record the interview?

YES NO

• We would like to get your permission to recontact you in the case that questions may arise after your participation in this interview. Do I have your permission to recontact you for future clarification?

YES NO

Procedures

• You may ask a question about this study at any time before, during or after the interview.

• You have the right to refuse to answer any question without penalty.

• We will provide you contact information for the project director, who you may contact with any questions that arise after your participation in this interview.

• Interviewer will take notes during the interview.

• You will receive a copy of this consent form.

Privacy

• We will take every precaution to protect your identity. Your responses to these questions will not be attributed to you and your name on the consent form will not be linked to your interview. CDC will have access to the interview notes, summaries and transcripts only after all identifying information has been removed. Interview data will be stored by ID number only.

Risks

• There are few risks to you for participating in this interview. Given that interviewer will ask respondents about disasters, we anticipate that some respondents may experience emotional or mental distress. If you feel distress for any reason, you are encouraged to stop the interview at any time with no penalty. The interview will only be resumed upon your verbal approval.

Benefits

• There will be no direct benefit to you from participating in this evaluation. The indirect benefit is that this research will likely yield knowledge about preparedness, response, and recovery. If you are not employed by the government, you will receive a $50 gift card. You will be asked to sign a receipt to show that you received the gift card. The receipt with your signature will not be stored with the consent form or any information gathered from the interview.

Your signature below indicates that you understand the above and agree to participate.

Contact information: If you have concerns about your rights in the study, contact Christine Walrath-Green, 40 Wall Street, 34^th Floor, NY, NY, 10005 or (212) 941-7031. Please sign below to indicate that you have read the above and agree to take part in this interview.

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THANK YOU