Att &_Assent Form: Tweens

ATSDR Task Order 15-4 Storyboard Testing

Attachment 7

Assent Form: Tweens¹

___________________________________________________

I, _________________________________________, agree to take part in this focus group discussion.

I understand that I do not have to be in this focus group. I can leave at any time. I can agree to be in the focus group and then change my mind later without any consequences.

I allow CommunicateHealth and the Agency for Toxic Substances & Disease Registry (ATSDR) to use the information from this discussion to make information about the dangers of trespassing better and easier to understand. I understand that the information is for a report only, and that my name will not be shared with anyone else.

I agree to ask questions about the discussion if I don't understand something. 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 I will be audio recorded during this focus group. I allow CommunicateHealth to transcribe the recording and write a report without my 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 my 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:                   _________________________________________