Consent

Attachment D

The MyMobility Study

Consent Form

What is the purpose of this research study?

The Centers for Disease Control and Prevention (CDC) has asked Battelle, a nonprofit organization, to obtain feedback on the MyMobility brochure. This tool contains information that should help people ages 60 or older to protect their ability to get places they need to go as they age. We hope you will participate in our focus group. We would like you to share your opinions about the information in the brochure and how CDC should distribute the MyMobility brochure to people your age.

What will I have to do if I am in this study?

If you choose to participate, you will take part in a focus group at a Battelle office. The focus group will last approximately 2 hours. During the focus group, you and the other individuals will be asked questions about the information in the MyMobility brochure and how you think CDC should distribute the tool. We will give you $75 for your participation.

What are the risks to being in this study?

Participation poses minimal risks to you. If you feel uncomfortable expressing your opinions and ideas, you can choose not to answer any questions you do not want to answer.

What are the benefits to being in this study?

You will not benefit directly from this study. However, the information you provide will help CDC decide how and where to distribute the MyMobility brochure.

What about the information I provide?

All the information you share with us will be kept private to the extent allowed by law. We will not include your name or other information in our notes or in any written reports that might identify you. We would like to audio record our discussion on a recorder. We will use recordings to make a transcript and to make sure we accurately capture what you say in our report. You will not be identified by name in either the recordings or transcripts. Only members of our study team will have access to the recordings and transcripts. Everything you share with us will be stored on a secure password protected electronic network. All the audio files will be deleted from recorders as soon as they are downloaded to the secure network. At the end of the project, all audio files in the secure network will be destroyed.

Do I have to participate in the focus group?

Your participation in this focus group is completely voluntary. You can decide whether to participate. If you agree to participate, you may stop at any time. You may also choose not to answer any questions you do not want to answer. There are no right or wrong answers.

What if I don’t have the opportunity to share something I want to share?

If we do not have the opportunity to capture something you want to share, we would still like to obtain your feedback. You are welcome to contact us with any additional comments.

What if I have questions?

Any question you have about the focus group can be answered before we begin our discussion. If you have any questions before or after the focus group, you may call the Battelle Project Leader Jennifer Brustrom at (209) 726-3458.

The Battelle Institutional Review Board (IRB) is an independent committee that reviews and approves human subjects research. If you have questions about your rights as a research participant, please call the Battelle IRB (toll-free) at (877) 810-9530, ext. 500.

Participant’s Consent to Participate

I understand the nature and purpose of the MyMobility Study, as described above. I understand the activities involved in the focus group and my rights as a participant. I agree to participate in the focus group.

Name of Participant (Print)

Signature of Participant Date

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