Consent Forms

TAB C

Consent and Confidentiality Forms

Opioid Public Education Program

Consent Form

Vanguard Communications is conducting focus groups on behalf of a federal health agency to inform the development of a public health education program. We expect this focus group to take about two (2) hours.

You are the expert on your experience and your thoughts and opinions are greatly valued and appreciated. We want to learn from you and we encourage you to speak openly and honestly about your experience. There are no right or wrong answers. Should you agree to participate in the discussion, here are some points you should know:

• Rights Regarding Participation: Your participation is completely voluntary. You may choose to leave the focus group and/or not answer a question at any time for any reason without penalty.

• Privacy: We will take every precaution to protect your identity and ensure your privacy unless otherwise determined by law. No individual participant will be identified or linked to the results and we will never use your name in any reports. Focus group records, including this consent form signed by you, may be inspected by the Substance Abuse and Mental Health Services Administration (SAMHSA) or the Office of Management and Budget which oversees all data collection conducted on behalf of government funded agencies. All materials will be stored in a secure location by Lake Research and access to files will be restricted to paid professional staff.

• Benefits: Your participation in the focus group will not result in any direct benefits to you. However, your input may benefit the public by informing the development of an education program aimed at reducing opioid misuse.

• Risks: No risk greater than those experienced in ordinary conversation are anticipated. Everyone will be asked to respect the privacy of the other group members. All participants will be asked not to disclose anything said within the context of the discussion, but it is important to understand that other people in the group with you may not keep all information private.

• Notes and Recording: The discussion will be recorded to help clarify the information written down by the note-takers, should there be any questions in summarizing the results. We will be using first names only during the focus group, and again, no quotes or comments you make would be linked with your name in any way.

• Observers: Individuals from SAMHSA may observe this focus group. They will not participate in the discussion. All observers have signed confidentiality forms stating that they will not discuss the specifics of the focus group.

• Questions: We will answer any questions you have about this focus group before you take part.

By signing below, you indicating that you fully understand the above information and agree to participate in this focus group.

Name: ______________________________________________________________________

Signature: ___________________________________________________________________

Date: ________________________________________________________________________

If you have any questions or concerns about this focus group, please contact Lisa Swanberg at [email protected] or (202) 248-5489.

Opioid Public Education Program

Observer Confidentiality Form

Vanguard Communications is conducting focus groups on behalf of a federal health agency to inform the development of a public health education program.

To protect the privacy of focus group participants and to foster an atmosphere of respect for all participants, it is important for all persons who observe the focus groups to accept the following conditions prior to observation:

• Observers should refrain from any conduct that will disrupt the focus group or interfere with the focus group process.

• Observers are present to observe only and not to take part in the focus group process.

• After the focus group has ended, observers shall not discuss the participant(s). Observers also should not discuss what was said by individual participants with others who were not also observers.

• Observers should keep their telephones and computers on mute while the focus group is in session so as not to disturb the process of moderating or note taking of the focus group.

By signing below, you indicating that you fully understand the above information and agree to participate in this focus group.

Name: ______________________________________________________________________

Signature: ___________________________________________________________________

Date: ________________________________________________________________________

8