Consent Form

Form Approved

OMB No.0920-0953

Expires XX/XX/XXXX

Consent to Participate in RTI Focus Group Discussion

Introduction

You are being asked to participate in a focus group discussion. Before you decide if you want to take part in this discussion group, you must read this Consent form so that you understand what the discussion group is about and what you will be asked to do. This form also tells you:

• who can participate in the focus group

• the risks and benefits of the focus group

• how we will protect your personal information

• who you can call if you have questions

If you have any questions about the information in this form, please ask the focus group facilitator before you decide whether to participate.

Purpose

This focus group discussion is being conducted by RTI International for the National Institute for Occupational Safety and Health (NIOSH). The purpose of today’s focus group is to get information and opinions about motor vehicle safety materials for your workers who drive as part of their job. You are one of approximately 40 participants who will take part in a focus group.

Procedures

Focus Group Discussion: If you agree to participate, you will be asked to join a focus group discussion with about 9 other people. During the focus group you will be asked to share your opinions and experiences with motor vehicle safety programs and materials.

Questionnaire: Before we start the focus group discussion, we have a brief questionnaire we would like you to complete.

Audio Recording: Today’s discussion will be audio-taped. We will use the tapes to prepare a summary of each group’s discussion; however, your name and employer will not be included in any reports. Once feedback from the focus group discussions are compiled, the audio recordings will be destroyed.

Transcripts: In addition to audio recording the discussion, we will prepare transcripts. To protect your privacy, only your first name will be used and your name and employer will not be associated with your responses or included in any documentation. Upon completion of the focus groups, we are required to store these transcripts for at least three years. Transcripts will be stored securely on a password-protected computer.

Public reporting burden of this collection of information is estimated to average 2 hours 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 (0920-0953).

Attendees: Staff members from NIOSH and RTI may be viewing tonight’s discussion.

Study Duration

Your participation in this focus group discussion will take no longer than 90 minutes.

Possible Risks or Discomforts

There are minimal psychological, social, or legal risks to participating in this focus group. You will be asked to share your attitudes and opinions in a group setting; however, tonight’s topic is not sensitive in nature. Your participation is voluntary, and you can choose not to answer any of the questions.

Benefits

There are no direct benefits to you from participating in this focus group. Your opinions will help us better understand how managers of small businesses think about motor vehicle safety materials.

Payment for Participation

You will receive $50 for your participation. This will be given to you at the end of the focus group session. You have the right to terminate your participation at any point, without penalty. If you must leave or are asked to leave for any reason before the conclusion of the session, you will receive the full incentive amount.

Confidentiality

We will take all possible measures to protect your privacy. To do this, we will only use your first name during the focus group discussion. Further, we will ensure that your name and employer are not included in any documentation.

The Institutional Review Board (IRB) at RTI International has reviewed the plan for the focus group discussions. An IRB is a group of people who are responsible for assuring that the rights of participants in the focus group are protected. The IRB may review the records of your participation in this focus group to make sure proper procedures were followed.

Future Contacts

We will not contact you in the future about this focus group.

Your Rights

Your decision to take part in this focus group discussion is completely voluntary. You can refuse to participate in any portion of this focus group and you can stop participating at any time. You can refuse to answer any question. If you decide to participate and later change your mind, you will not be contacted again or asked for further information.

Your Questions

You may ask questions or express concerns about this consent form, the focus group, your rights as a participant, or report problems (e.g. any injuries related to your participation) at any time before, during, or after the focus group. You may contact Jennifer Alexander of RTI at 301-770-8219. If you have concerns about how you are treated in the focus group, you may contact RTI’s Office of Research Protection toll-free at 1-866-214-2043.

YOU WILL BE GIVEN A COPY OF THIS CONSENT FORM TO KEEP.

Your signature below indicates that you have read the information provided above, have received answers to any questions you may have, and have freely decided to participate in this focus group. By agreeing to participate, you are not giving up any of your legal rights.

______________ ___________________________________ _ Date Signature of Participant

___________________________________ _ Printed Name of Participant

I certify that the nature and purpose, the potential benefits, and possible risks associated with participating in this focus group discussion have been explained to the above-named individual.

______________ ___________________________________ _ Date Signature of Person Obtaining Consent

___________________________________ _ Printed Name of Person Obtaining Consent

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