Focus Group Enrollment and Waiver Form

Attachment M –Focus Group Enrollment and Waiver Form, Word Version

Note: This form will be available online for completion

1. Name (optional):

2. Work email address:

3. Work telephone number:

4. Health department/agency name:

5. (Choose Only One) Based on the level of government (i.e., state/territorial; or local) organization where you work, please choose a focus group in which you like to participate during the 2019 National Association of County and City Health Officials (NACCHO) Preparedness Summit.

   • (State/Territorial) Group 1: March 27, 2019; time TBD ☐

   • (Local) Group 2: March 27, 2019; time TBD ☐

   • (State/Territorial) Group 3: March 28, 2019; time TBD ☐

   • (Local) Group 4: March 28, 2019; time TBD ☐

CDC | cNA

Recognizing Best Practices In Training and Exercises for Public Health Emergency Response Leaders in Incident Management

Focus Group Discussion

RECORDING CONSENT AND WAIVER FORM

I hereby give the Institute for Public Research at CNA and Johns Hopkins University (JHU) permission to record my name, voice, likeness, and any and all attributes of my personality electronically during the in-person and/or virtual focus group discussion. I understand that the recording will be stored on a secure, password protected server. CNA/JHU has my permission to use the recording to gather data to identify best practices and gaps in the training and/or development of public health emergency response leaders across state and local health departments and agencies. I understand that any data collected during the in-person and/or virtual focus group discussion or from the recording of the focus group discussion will be shared only in aggregate form and I will not be individually identifiable. CNA/JHU has my permission to collect data in aggregate form from the recording and edit, publish, print, or create derivative works of the data for training and any other lawful government purpose, and to authorize others to do the same.

I waive any right that I may have to inspect and approve the finished product that may be used or to which it may be applied now and/or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the recording or product.

I release and agree to hold harmless CNA/JHU, officers, employees, faculty, agents, nominees, departments, and/or others for whom or by whom CNA/JHU is acting, of and from any liability by virtue of recording of video or using the testimonial/biographical data, in any progressing tending towards the completion of the finished product, and/or any use whatsoever of such products, whether intentional or otherwise.

By clicking SUBMIT, I indicate that I have read, understood, and agree to the information stated in these forms and am willing participate in and be recorded during a focus group.

To submit these forms, please [CLICK HERE TO SUBMIT]

Thank you for your interest in participating in a focus group discussion. You will receive a confirmation email from CNA/JHU with instructions for joining the discussion. The CDC will not have access to any individually identifiable information collected by CNA/JHU as the project’s contractor team. For any questions or concerns, please email ([email protected]).

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