Focus Group Consent Form

A Tailored Communications Campaign to Reduce Pregnancy-Related Complications and Death

Attachment 4: Consent Form for Focus Group Participation

A Tailored Communications Campaign to Reduce Pregnancy-Related Complications and Death

Consent Form for Focus Group Participation

Participating Institutions: Centers for Disease Control and Prevention (CDC), MarketVision, V&L Research and Consulting, Inc.

Introduction and Purpose:

V&L Research and Consulting is conducting focus groups with currently pregnant and recently postpartum women and a member of their support system, such as a spouse or partner, family member, friend, or doula, to understand how these audiences perceive messaging intended to reduce the risk of severe pregnancy-related complications and deaths. Information gathered from these focus groups will help improve public health communication messaging on this topic among pregnant and postpartum women, as well as members of their support system.

This focus group will take about three hours. During this time, we will discuss health communication materials that have been developed to reduce the risk of severe pregnancy-related complications and deaths.

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

• Participant Rights: This discussion is completely voluntary. You may choose to leave the focus group and/or not answer a question at any time for any reason.

• Privacy: We will take every precaution to protect your identity and ensure your privacy to the extent permitted by law. We will keep your name and contact information private. Your contact information will be kept separate from any focus group responses, and all responses will be summarized anonymously. We also will never use your name in any reports. After we have completed our reports, all notes, audio recordings, and electronic files will be destroyed.

• Benefits: Your participation in the focus group will not result in any direct benefits to you. However, your thoughts and opinions will help to develop a communications campaign intended to reduce the risk of severe pregnancy-related complications and deaths among women in the United States.

• Risks: The focus group poses minimal, if any, risks to you. We will ask your opinions about messaging related to reducing the risk of severe pregnancy-related complications and deaths. You may talk about how your current or previous pregnancy, or your experience supporting a pregnant or postpartum woman, affects your opinion.

• Incentive: In appreciation of your time, you will receive a $75 cash gift card for participating in today’s focus group.

• Audiotaping and Notes: The discussion will be audio-recorded. No quotes or comments you make will be linked with your name in any way. We may take notes throughout the focus group today to help us keep track of your responses. We will keep all information, notes, and audiotapes locked in a file cabinet or a secure computer file. Only project staff will be able to access the information. These notes and audio recordings will be destroyed upon conclusion of the project.

• Observers: Individuals from the project team will be observing this focus group silently. They will not participate in the discussion.

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

What if I want to stop before my part in the concept testing is complete?

Taking part in this focus group is voluntary. You do not have to participate if you do not want to. If you agree to participate, but later change your mind, you may drop out at any time for any reason. There are no penalties or consequences of any kind if you decide that you do not want to participate. During the focus group, you may choose not to answer any questions.

Your Consent

I have read this consent form. I had a chance to ask questions, and my questions were answered. I was given a copy of this consent form. I agree to participate in the focus group.

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The above document describing the benefits, risks, and procedures for this focus group has been explained to me. I agree to participate.

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Signature of Participant Date

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Signature of Person Obtaining Consent Date

Flesch-Kincaid Grade Level: 9.7