Verbal Consent - Key Informant Interview - English

VERBAL CONSENT FORM: Key Informant Interview

US-Based Migrant Farm Workers Understanding and Use of Measures to Prevent Zika Transmission

Purpose

Our talk together will take about an hour. We want to hear about your experiences and opinions about a new disease called Zika. Partner groups that work with farm workers picked this farm/cooperative as a place where workers might be willing to talk to us. We are also talking to workers in [GA, TX, FL, CA]. We are talking to both men and women.

Procedure

We will tape record what you say and write notes. We will not write down your name in the notes or anything else that might let someone know who you are. We will not take any photos. After our interview, project staff will listen to the tapes and type notes about what was said. They will take out any names that you mention. This way, no one who reads the notes will know who you or the people you have talked about are.

Risks

There is little to no risk to talking to us. It is up to you if you want to be in the group talk. Whether you agree to talk with us or not will not affect your job in any way. We will not write down who talks to us or who does not talk to us. We will not tell your employer whether or not you to talk to us.

If we ask a question that you do not want to answer, you don’t have to. You may say that ‘you do not know’ if you have don’t know the answer to a question. There are no right or wrong answers to the questions. You will not get into trouble for anything you say. We will not ask about your immigration status. You are free to stop and leave at any point.

Benefits

If you decide to talk to us, you may learn more about Zika and ways to prevent getting sick. We will be happy to share some written health information in Spanish.

Confidentiality

Nothing that is sent back to CDC will have your name or anything else that someone could look at and know was about you. We do not have any papers with your name on them.

We will ask you to let us tape record our talk and take notes about what you say. This helps us to make sure we know exactly what you have said. We will listen to the recording and type notes about what was said. We will erase the recording after we check that the notes are correct. We will keep the tapes and notes locked in a file cabinet. We may use some of what you say in a report that we write but we will not use your name or anything else that could let people know who you are. Any exact quotes will be anonymous.

Do you have any questions about how we will keep your information private?

Do you have any questions?

CONSENT

Do you agree to talk to us?

Date and State [GA, FL, TX, CA]:

Do you allow us to write down what you say?

Date and State [GA, FL, TX, CA}:

Do you allow us to use the tape recorder?

Date and State [GA, FL, TX, CA}: