Consent for SS women - English

Antibiotic Use Campaign - Informed Consent Form

Consumer Focus Groups

On behalf of the Centers for Disease Control and Prevention (CDC), ICF is conducting focus groups with adults from the community to gather feedback on educational materials developed to help raise awareness about appropriate antibiotic use. These materials were developed in partnership with the CDC. We hope to use what we learn from these focus groups to improve these materials and/or develop new ones. We expect each focus group to take about 75 minutes.

We want to learn from you, so we encourage you to speak openly and honestly. There are no right or wrong answers. If you agree to participate in the discussion, here are some points to know:

• Rights Regarding Participation: Your participation in 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. Refusal to participate will involve no penalty or loss of benefits.

• Privacy: We will take every precaution to protect your identity and ensure your privacy. We will keep your name and answers to these questions private. Your name and contact information will be kept separate from any focus group responses. We will never use your name in any reports.

• Benefits: Your participation in the focus group will not result in any direct benefits to you. However, your input will help us to develop and improve educational materials about appropriate antibiotic use for people like you.

• Risks: There is no known risk to you for your participation in the focus group. We have made every effort to remove any risk to you from participating in this focus group. However, you may choose not to answer any questions that make you feel uncomfortable in any way.

• Incentive: We appreciate your time and participation. The recruiter will give you $XX as a token of appreciation for participating in today’s focus group.

• Recording: We will record this discussion. Again, no quotes or comments you make will be linked with your name in any way. We will take notes during the discussion to keep track of the responses from all of the participants. We will keep all information, notes, and recordings locked in a secure computer file. At the end of the project, the notes and recordings will be destroyed. Only study staff will be able to access the information.

• Observers: Individuals from CDC will silently observe this discussion. They will not participate in the discussion. All observers have completed training related to your privacy and confidentiality.

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

• Contact Information: If you have any questions about this discussion or the campaign, please contact the research director, Kristen Cincotta, PhD, at 404-320-4433. If you have questions about your rights as a participant in this focus group, please contact the chair of ICF’s Institutional Review Board (IRB), Carole Harris, at (404) 321-3211.

Do you consent to participate in the focus group?  Yes  No

Do you agree to be recorded during this discussion?  Yes  No

Name (please print): ___________________________________________________________________

Signature: ______________________________________________ Date: ___________________