0920-0572 Testing of brand concepts Appendix B2-Consent form-

Appendix B: Consent Form Form Approved

HCP Triads OMB No. 0920-0572
Expiration Date: 2/28/2015

Informed Consent Form

Identification of Project	CDC Discussion Groups
Purpose	The Centers for Disease Control and Prevention (CDC) is the sponsor of this project. FHI 360 is helping with this project. The purpose of this project is to gather feedback regarding potential branding, messages, and other communication materials related to a diabetes prevention program. It will help inform how CDC and its partners can better communicate certain health-related information to different audiences.
Procedures	We have asked you to join a triad (small group discussion). The discussion will take place over the phone and computer. During the discussion, you will be asked about your thoughts and opinions regarding several materials, messages, and ideas related to a diabetes prevention program. The group will have up to three other people. The group will last no more than 60 minutes. A trained person will lead the discussion group.
Information Security	We will make audio recordings of the group. In addition, some people who work on the project may listen to the recordings and may also listen during the discussion group. They will write a report based on their notes and the recordings. However, no one outside of this project will listen to the recordings. We will keep what you say secure to the extent permitted by law. We will NOT put your name in the report or on the recordings. We will keep the recordings in a locked cabinet. The recordings will be destroyed by 2015.
Risks	I understand that the risks of my participation are expected to be minimal. This means that the risks are not expected to be greater than the risks a person may normally find in their daily life.
Benefits, Freedom to Withdraw, & Ability to Ask Questions	This project is not designed to help you personally. It is intended to help CDC understand how to best communicate certain health-related information to different audiences. You do not have to answer questions that you do not want to answer. You may stop at any time. You will receive $50 to show appreciation for your participation.
Contact Information	If you have any questions, please contact Rebecca Ledsky at [email protected] or 202-884-8814. You may ask her about your rights as a project participant. You may contact her with any concerns about participating in the discussion group.

My signature confirms that I have read the information on this page. I understand my rights as a participant. I agree to take part in this discussion group. I agree to have audio recordings made of the discussion. I realize that only the people working on this project will listen to the recordings and that they may also listen during the discussion groups. I understand that my name will NOT be used in the report or any other products. No other information that could identify me will be used either.

Signature: ________________________________________________________

Name (Please print): ________________________________________________

Date: ___________________________