Appx K_Consent Form

Appendix K: Consent Form

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

I understand that I do not have to be in this study. I can discontinue participation at any time without penalty. I can agree to be in the study and then change my mind later.

I allow the Centers for Disease Control and Prevention (CDC) to use the information from this discussion. I understand that the information is for a report only, and that my name will not be used in the report.

I agree to ask questions about the discussion if I don't understand something. If I have questions after the study is over, I can contact Rachel Pryzby, Health Communication Manager, at [email protected] or (413) 582-0425. 

Audio Recording Release

I understand that I will be audio recorded during this study. I allow CommunicateHealth to use the recordings of me for report-writing purposes only. I understand the recording will not be transcribed. 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:                   _________________________________________