Consent

Attachment A: Informed Consent Form for Pregnant and New Mother Oral Health Focus Groups

Informed Consent Form

Identification of Project	Health Issues Research
Statement of Age of Subject	I state that I am at least 18 years of age, in good physical health, and wish to participate in a program of research being conducted by Salter>Mitchell in office at [INSERT LOCATION]: _________________________.
Purpose	The purpose of this research is to understand health issues facing women who are pregnant or have young children.
Procedures	Study participants will participate in a group discussion that will last approximately 90 minutes.
Risks	I understand that the risks of my participation are expected to be minimal in nature.
Benefits, Freedom to Withdraw, & Ability to Ask Questions	I understand that this study is not designed to help me personally but that the investigators hope to use the research findings in order to develop procedures and communications that may benefit people like me more broadly. I am free to ask questions or withdraw from participation at any time and without penalty.
Contact Information of Investigators	Name: Robert Bailey Position: Research Director, Salter>Mitchell Telephone: 703.683.2240 Email: [email protected]

Printed Name of Research Participant _____________________________

Signature of Research Participant ________________________________

Date______________________

OMB #: 0920-0572 Exp. 3/3/2018