Consumer perceptions as a foundation for CTP positioning initiative

Informed Consent for Participation in a Discussion Group

ADULT FOCUS GROUP

Affini LLC is conducting discussion groups on behalf of a health promotion agency to better understand consumers’ thoughts and knowledge about health, health products, tobacco, advertising and marketing. We have invited you to participate in a discussion with other consumers to share your thoughts and knowledge about these subjects.

If you consent to participate in the discussion, here are some things you should know:

• Your participation is totally voluntary.

• Your name will not be used in any reports about this discussion group. We will be taking notes during the discussion about what was said, but we will not record who made the comments.

• The discussion will be audio- and video-taped so that when we write our report we can make sure we understand everything that was said.

• There will be observers from the health promotion agency and Affini LLC in another room taking notes during this discussion.

• Anything discussed during the group will be kept private

• You will receive $50 for participating in the group.

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

• The discussion group will last approximately two hours.

• Any questions you have about the discussion groups will be answered before we begin our discussion. Contact information is provided below for any questions that arise after the discussion.

• You will be provided with a copy of this form to take with you.

Contact information: If you have any concerns about your participation in this

discussion group or have any further questions about the project, contact Ms. Kirsty Afshar at Affini LLC, telephone number (203) 249-2858.

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

Print your name: _________________________ Date: __________________

Signature: ______________________________ Witness: __________________