2 Informed Consent Form

ATTACHMENT 2: INFORMED CONSENT FORM

Form Approved

OMB No. 0925-0648

Exp. Date 05/2021

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A 60-minute virtual (online/by phone) focus group with

Persons Diagnosed With

Temporomandibular Disorders (TMD)^*

to Discuss Feedback on a Brochure

Day Month, 2020

INFORMED CONSENT FORM

Please read the list of statements below about this virtual (online/by phone) focus group sponsored by the National Institute of Dental and Craniofacial Research, part of the National Institutes of Health. If you agree with the statements, please print and sign your name at the bottom of this form. This information will be kept in a secure place. This information will never be connected to any opinion or comment that you make during the focus group discussion.

I understand that:

• I will participate in an approximately 60-minute focus group discussion with up to 3 other participants and a moderator.

• My participation is completely voluntary.

• I may decide to stop my participation at any time.

• I do not have to answer any question I don’t feel comfortable with.

• I may be excused if I am more than 10 minutes late to the focus group discussion.

• A trained focus group discussion moderator will facilitate the discussion.

• The focus group discussion will be about a Temporomandibular Disorders brochure.

• I will be mailed the Temporomandibular Disorders brochure ahead of time and expected to read it before the focus group.

• The project team will keep confidential my name and opinions.

• All participants will use their first names only (no last names) during the entire focus group discussion.

• The facilitator will audio record the focus group discussion. (There will be no video recording of the focus group discussion.)

• Project staff may listen to the focus group discussion, and a notetaker will be on the line to take notes.

• The project team will only use the findings from the focus group discussion to inform the development of a final Temporomandibular Disorders brochure.

• No one will try to sell me anything.

• My information will not be shared with/sold to anyone.

• I will receive a token of appreciation for participating.

• I will plan to dial in approximately 10 minutes prior to the start of the focus group discussion call.

• I had the opportunity to ask questions about this project and I have received satisfactory answers.

I agree to participate in this focus group discussion.

_____ Yes

_____ No

Print your name: ____________________________________________

Sign your name: ____________________________________________

Date: ___________________

*Temporomandibular Disorders (TMD)” are also commonly called “Temporomandibular Joint (TMJ) Disorders.”