Consent

Attachment B – Informed Consent Form

Form Approved

OMB No. 0920-0572
Exp. Date 3/31/2018

CDC Air Quality Information Project

Consent Form

Introduction and Purpose:

Thank you for agreeing to participate in a study about air quality and health. The purpose of the study is to get your feedback on educational materials about these topics.

RTI International, a non-profit research organization in North Carolina, is conducting the study. We will be conducting group discussions with people in Atlanta, GA; Detroit, MI; and Denver, CO. You are one of approximately 27 people being asked to participate in this study.

You are eligible to participate in this study because you have one of several health conditions mentioned in the educational materials.

Procedures:

If you agree to participate, you will take part in a group discussion (3 people) about air quality and health. The discussion will last about one hour.

Benefits:

There is no direct benefit to you for participating. However, you may find the discussion informative and may learn how air quality affects people’s health.

Risks:

There are no known risks to participating in this study. While the questions we ask are not meant to be sensitive, there is always a chance that you may feel uncomfortable with some of the questions. You do not have to answer any question that you don’t want to answer.

Privacy:

We will try to keep the information you share in this group secure. The study team will not disclose your name or any of your comments, and your personal information (name, address, phone number) will not be linked to any of your responses. We also will ask the other participants not to disclose anything that was discussed in the group. However, we cannot control what other participants say after the group is finished.

CDC estimates the average public reporting burden for this collection of information as 5 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 Information Collection Review Office, MS D-74; 1600 Clifton Road NE, Atlanta, Ga. 30333; OMB No. 0920-0572.

With your permission, we will audio record the discussion to supplement our notes. Recordings will not include full names and will be stored on password protected computers that only project staff can access. At the end of the project, we will destroy the recordings. All hardcopy forms will be kept in a locked file cabinet that only project staff can access.

Observation:

Some project staff may listen to the discussion by phone. They will not record your name and will keep all of your comments secure.

Token of Appreciation:

In appreciation for your time, we will provide you with $40 at the end of the group discussion.

Right to Refuse or Withdraw:

Your participation in this study is voluntary. You can choose not to talk about any topic, and you can withdraw from the group for any reason at any time without penalty.

Persons to Contact:

If you have questions about the study, you can call the project director, Mr. Doug Rupert, at 1-800-334-8571, ext. 26495 (toll free). He can be reached between 9:00 AM and 5:00 PM Eastern Time Monday to Friday.

If you have questions about your rights as a participant, you can call RTI’s Office of Research Protection toll-free at 1-866-214-2043.

Your Consent:

I have read this consent form. I had a chance to ask questions, and my questions were answered. I was given a copy of this consent form. I agree to participate in the study.

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Signature of Participant Date

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Signature of Person Obtaining Consent Date