Focus Group Consent

STUDY: Focus Group for Minority Men

STERLING IRB ID: 7292-KEdwards

PARTICIPANT INFORMED CONSENT FORM

STUDY TITLE: Reaching Minority Men Where They Are

STUDY DOCTOR: Kerstin Edwards

STUDY SITE: Leavitt Partners

299 South Main St, Suite 2300

Salt Lake City, UT 84111

TELEPHONE: 801-326-3576

SPONSOR: Centers for Disease Control and Prevention

WHAT IS THIS ABOUT?

This form is to tell you about a research study we want you to participate in. We will ask you to answer questions about your health behavior and what you like and don’t like about health programs. We will use the answers you give to figure out what types of programs are helpful to minority men. You get to choose whether you participate in this focus group. You can say “no” for any reason. You don’t have to tell us why you say “no”.

WHAT EXACTLY DO I HAVE TO DO?

We are asking you to participate in a focus group. A focus group is 8-10 people sitting around a table and talking about some questions. In this case we are going to ask you to discuss your thoughts and feelings about your health and your participation in programs that are supposed to make you healthier.

WHO IS BEING ASKED TO PARTICIPATE IN THE FOCUS GROUP?

We are asking minority men or men of color who are age 18 and older to answer the focus group questions.

WHO IS DOING THIS STUDY?

The study is being sponsored by the Centers for Disease Control and Prevention (CDC) and the National Association of Chronic Disease Directors (NACDD). Leavitt Partners is working with CDC and NACDD to conduct the focus groups. The person in charge of the focus groups is Kerstin Edwards.

WHO WILL GET INFORMATION ABOUT ME IF I PARTICIPATE IN THE SURVEY?

Researchers at Leavitt Partners will collect the answers and study them. Your name will not be included with the final answers. No one will be able to tell that it was you who gave the answers.

WHAT ARE THE POSSIBLE RISKS OR DISCOMFORT INVOLVED FROM BEING IN THIS FOCUS GROUP?

The focus group will not put you in any danger. There is a small chance that when you think about your health or health care you may remember something that upset you in the past. We don’t think this is likely to happen. But if you do feel upset or remember feeling upset, you may leave the focus group at any time. There is also a very small chance you might see someone you know while you are participating. If that happens and you feel uncomfortable, you may leave. We have asked everyone who participates to respect each other’s privacy. You will not lose any benefits or services to which you would otherwise be entitled if you decide not to participate in this focus group.

HOW MUCH TIME WILL I NEED TO GIVE?

We will spend about 10 minutes helping you understand everything on this form. If you decide to be in the focus group, the whole thing will last about 90 minutes. This does not include the time it takes you to travel to and from the place we are holding the focus group. We will only ask you to participate one time.

WHAT ARE THE POSSIBLE BENEFITS AND COSTS FROM BEING IN THIS STUDY?

You will not be paid or get other benefits for taking being in this focus group. If you complete the focus group, you will receive a gift card valued at $75.

HOW WILL MY PRIVACY BE PROTECTED?

One way we protect your privacy is by not asking for your name on this form or during the focus group. You can use a first name you choose during the focus group. Another way we protect your privacy is that only the people who set up the focus group will have your real name and phone number. This information will not be shared with researchers. You should know that this focus group will be recorded. This is so we can capture all of the things you say correctly. We protect your privacy by making sure only a small number of people from Leavitt Partners review the video and audio files from the focus group. We will destroy the recordings at the end of the year.

In rare cases, persons who may have access to your focus group results include staff from the Office for Human Research Protections in the Department of Health and Human Services, or other federal, state, or international regulatory agencies, and the Sterling Institutional Review Board. The results from this focus group will not be published in a journal or magazine. All information will remain private except where disclosure is required by law.

MAY I WITHDRAW, AT A FUTURE DATE, MY CONSENT FOR PARTICIPATION IN THIS RESEARCH STUDY?

If you decide to be in the focus group and then change your mind, you may withdraw your consent. If you want to withdraw your consent, you need to do it before you leave the group. After that, all of the answers will be put together and it will be hard to tell which answers are yours.

WHAT IF I HAVE QUESTIONS ABOUT THIS STUDY, THE SURVEY, OR ABOUT MY RIGHTS AS A RESEARCH PARTICIPANT?

You have the right to ask, and have answered, any questions you may have about this research study.

If you have questions, concerns or complaints about the research study or you experience a research-related injury, please contact Kerstin Edwards or the study staff at 801-538-5082.

If you have questions regarding your rights as a research participant, or if you have questions, concerns, complaints about the research, would like information, or would like to offer input, you may contact the Sterling Institutional Review Board Regulatory Department, 6300 Powers Ferry Road, Suite 600-351, Atlanta, Georgia 30339 (mailing address) at telephone number 1-888-636-1062 (toll free).

Thank you for reviewing this form. Please ask us any additional questions you have about this research. Please read the consent statement below. You will get to keep a copy of this form in case you want to look at it later.

CONSENT

I have read the information provided above. I have asked all the questions I have at this time. I voluntarily agree to participate in this research study. I provide consent by participating in the focus group.

Name

You may sign this form if you want to, but your signature is not expected nor required.

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Version Date: March 1, 2019

DATE APPROVED BY STERLING IRB: 06/13/2019