Form 1 Attachment 1 Focus Group Informed Consent

Informed Consent (revised)

As part of a project for the Health Resources and Services Administration (HRSA), Crosby Marketing is conducting a focus group to get the thoughts of your son/daughter.

If you allow your child to be in the group, here are some things you should know:

• It is up to you and your child to decide if he/she wants to be in the group.

• Being in the focus group should not harm your child. He/she may not want to answer every question. He/she does not have to answer all the questions if he/she does not want to. If you would like more information about this, please let us know.

• Your child’s name will not be used in any reports. We will take notes. We also audio-record the group to make sure our notes are correct, but we do not keep these tapes once we have checked our notes. Other people on our team may also be watching the groups so they can hear the ideas, too.

• Your child will receive money as a thank-you for taking the time to be in the group.

• Your child can leave the group at any time, or not answer any question, and he/she will still get the money for his/her time.

• Being in the group will not change any existing relationship you or your child have with HRSA (for example, if you go to a HRSA clinic) or anything else about other Federal programs you may be in.

• If you have any questions, please ask them now. If you think of a question later, please call the person listed below.

• The focus group will last approximately 2 hours.

Contact information: If you have any questions, please contact Mike Cosgrove at 301-951-9200.

Please sign to say that you understand this information and agree to allow your child to be in the focus group.

Print the name of your child: ______________________________________

Print your name: _________________________ Date: _________________________

Signature: _________________________