Informed Consent and Rescreening Form

CONSENT FORM

Please read this form carefully. If you decide to take part in this study by participating in this focus group, you must sign the end of this form.

Westat is conducting research to develop health education materials on skin cancer prevention and safe sun practices. The research will consist of completing a short questionnaire and participating in a 120-minute focus group discussion with up to 9 other individuals. The Centers for Disease Control and Prevention (CDC) is sponsoring this study and Westat, a research firm, is conducting this study. Your input is very important, as it will assist health agencies with creating useful health promotion and education materials.

Your participation in this research is completely voluntary. You can refuse to answer a question or withdraw from the focus group without consequences to health services you may receive. There are no known risks or benefits from taking part in this focus group.

Everything you say in the focus group will be kept private. The report summarizing the findings will not contain any names or identifying information. Everything shared during the focus group sessions should remain in the session and not shared with anyone outside the group. The focus group will be audiotaped; only staff directly working on the research will have access to the recordings. The audio files will be stored securely and only our research team will have access to them. The audio files will be destroyed at the end of the study.

As a token of appreciation for your participation, you will receive $75 at the end of the focus group discussion.

If you have any questions about the study, please ask the person who provided this form to you. If you have questions about your role as a research participant, please contact the Westat Human Subjects Protections Office at 1-888-920-7631. Please leave a message with your full name, the name of the study that you are calling about (skin cancer focus group study), and a phone number beginning with the area code.

If you agree to participate in this study, please sign the following statement:

I have read this consent form and understand the proposed project.

I consent to participate in this study.

Participant: ___________________________ ________________________

(Print name) (Signature)

Date: _______________________________

Form Approved

OMB No. 0920-0572

Exp. Date 03/31/2018

RESCREENER

Public reporting burden of this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0572)

[LOCATION OF GROUP]

[DATE OF GROUP]

1. Name (First name Last initial):______________

[PLEASE DO NOT WRITE YOUR LAST NAME]

2. City/Town of residence: __________________

3. Age: ______

4. Natural hair color:_________

Eye color: ____________

5. Which of the following best describes your ethnicity?

( ) Hispanic or Latino

( ) Not Hispanic or Latino

6. Which of the following best describes your race? [CHECK ALL THAT APPLY]

( ) American Indian or Alaska Native

( ) Asian

( ) Black or African American

( ) Native Hawaiian /Other Pacific Islander

( ) White

7. Are you:

[CHECK ONE]

( ) Married

( ) Never married

( ) Divorced or separated

( ) Widowed

( ) Living with a domestic partner

8. What is the highest level of education you have completed?

[CHECK ONE]

( ) Less than high school

( ) High school graduate/GED

( ) Some college or associates degree

( ) 4-year college graduate

( ) Post-graduate degree

9. Are you:

[CHECK ALL THAT APPLY]

( ) Employed full-time

( ) Employed part-time

( ) Unemployed

( ) Retired

( ) Student

10. Occupation (if applicable): _____________

11. Name of organization where you work (if applicable): _________________________

12. Spouse/partner’s occupation (if applicable): ___________________________________

13. How many focus groups have you ever attended? _______

14. What was the subject of those focus groups? ___________________________________

___________________________________

PLEASE TURN OVER 

15. In the past 12 months, have you ever used an indoor tanning device?

( ) Yes

( ) No

16. If you went out in the sun for an hour without sunscreen, a hat, or protective clothing, which one of these best describes what would happen to your skin? [CHECK ONE]

( ) Get a severe sunburn with blisters

( ) Have a moderate sunburn with peeling

( ) Burn mildly with some or no tanning

( ) Turn darker without sunburn

( ) Nothing would happen to my skin

17. Which of the following do you visit and USE multiple times per week? [CHECK ALL THAT APPLY]

( ) Google search

( ) Facebook

( ) Twitter

( ) YouTube

( ) Snapchat

( ) Instagram

( ) Personal or work email

18. What magazines do you regularly read?

1. _____________________________

2. _____________________________

3. _____________________________

19. What TV/radio shows do you regularly go to for your news?

1. _____________________________

2. _____________________________

3. _____________________________

20. What newspapers/websites do you regularly read for your news?

1. _____________________________

2. _____________________________

3. _____________________________

PLEASE RETURN THIS QUESTIONNAIRE TO YOUR HOST OR HOSTESS.