Att 6_ Consent Form: Parents of Tween

Attachment-6_Consent-Form-Parent-of-Tween.docx

CDC and ATSDR Health Message Testing System

Att 6_ Consent Form: Parents of Tween

OMB: 0920-0572

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ATSDR Task Order 15-4 Storyboard Testing

Attachment 6

Consent Form: Parents of Tween Participants1

___________________________________________________


I, _________________________________________, agree to let my child ________________ take part in this focus group discussion.


I understand that ______ [child’s initials] does not have to be in this focus group and can leave at any time. ______ [child’s initials] can agree to be in the focus group and then change his/her mind later with no consequences or effect for not participating.


I allow the Agency for Toxic Substances & Disease Registry (ATSDR) to use the information from this discussion. I understand that the information is for a report only, and that ______ [child’s initials] name will not be shared with anyone else.


I agree to ask questions about the discussion if I don't understand something that ______ [child’s initials] is being asked to do as part of this focus group. If I have questions after the focus group is over, I can contact Mary Ann Petti at [email protected] or at 413-582-0425.



Audio Recording Release


I understand that ______ [child’s initials] will be audio recorded during this focus group. I allow CommunicateHealth to transcribe the recording and write a report without ______ [child’s initials] name to improve the materials. I understand that CDC and ATSDR will not have access to the audio recordings. I understand that the recording will be destroyed and ______ [child’s initials] name will not be used for any other purpose.


Summary


I have read and understood this consent form. I understand that I will get a copy of this form.


Print Name:         _________________________________________


Signature:           _________________________________________


Date:                   _________________________________________


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorSandra Williams Hilfiker
File Modified0000-00-00
File Created2021-01-25

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