Observer Confidentiality Agreement

OMB No. xxxx-xxxx

Expiration Date: xx/xx/xx

Public Burden Statement: 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. The OMB control number for this project is xxxx-xxxx. Public reporting burden for this collection of information is estimated to average less than 1 minute per respondent, per year. 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 0920-1154.

Antibiotic Use Campaign – Observer Confidentiality Form

Consumer Focus Groups and Healthcare Professional Interviews

ICF is conducting interviews with health care professionals (HCPs) and focus groups with consumers on behalf of the Centers for Disease Control and Prevention (CDC) to inform the development of messages, concepts, and materials for a communications campaign on appropriate antibiotic prescribing and use.

To protect the privacy of interview and focus group participants and to foster an atmosphere of respect for all participants, it is important for all persons who observe the interviews and/or focus groups to accept the following conditions prior to observation:

• Observers should refrain from any conduct that will disrupt the interview/focus group or interfere with the interview/focus group process.

• Observers are present to observe only and not to take part in the interview/focus group process.

• After the interview/focus group has ended, observers should not discuss the participant(s). Observers also should not discuss what was said by individual participants with others who were not also observers.

• After the interview/focus group has ended, observers should refrain from discussing specifics about the interview/focus group. Discussions should be general in nature and only with other individuals who were also observers.

• Observers should keep their telephones and computers on mute while the interview/focus group is in session so as not to disturb the process of moderating or note taking of the interview/focus group.

Your signature below indicates that you understand and accept these conditions.

Name:

Signature:

Date: