Consent

Attachment C-1. Consent Form - English

Participant Consent Form

About the Project

You are invited to participate in a focus group talk with others from the general public. Your participation will help public health planners understand what the general public thinks about a health topic. The talk will last about 2 hours. A trained leader will lead the discussion. The results will help public health planners design and refine a health campaign. Information from today’s focus group might be shared with the public through a journal publication.

We will audio and video record this talk and transcribe information. Individual names will not be included in the written notes. We do not plan to allow anyone outside of this project to listen to, watch, or read anything that is recorded. All that you say will be kept private to the extent permitted by law. Your name will not be used in any reports or publications resulting from the focus group discussion. We will make the information collected from the focus group discussion available to the project team during analysis and no names will be included on this information. The information will be kept in a locked cabinet. We plan to destroy all the information following analysis.

We do not foresee any risks to you from participating in this study. Your participation is voluntary and you do not have to answer any questions or discuss any issues that you do not want to discuss. You may stop participating at any time. This project is sponsored by the Centers for Disease Control and Prevention. If you have any questions about this project, please call Cynthia A. Gelb at 770-488-4708.

If you have questions about your rights as a participant in this project or think you have been harmed, please call 1-800-584-8814. Leave a message with your name and phone number, and someone will call you back as soon as possible.

We thank you for your time.

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My signature verifies that I have read About the Project and understand my rights as a participant. I agree to participate in today’s discussion. I understand that the group will discuss health topics. I agree to be audio-taped, video-taped, and observed. I understand that only the people working on this project will be given access to the audio-tape, video-tape, and transcription. I understand that CDC will not use my name or any other identifying characteristic in any report or other products that may result from this project.

Signature: ________________________________________________________

Name (Please print): ________________________________________________

Date: ___________________________