Post Pilot Feedback Interview Consent Form

Form Approved

OMB No. 0920-XXXX

Expiration Date: XX/XX/XXXX

LGBTQ Inclusivity Toolkit Demonstration Project

Post-Pilot Feedback Interview Consent Form

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

LGBTQ Inclusivity Toolkit Demonstration Project

Post-Pilot Feedback Interview Consent Form

Thank you for agreeing to meet with us today. I am ________ and my pronouns are ________. I work for a company called ICF. As you are aware, we are working with the Centers for Disease Control and Prevention’s (CDC) Division of Adolescent and School Health (DASH) to develop an LGBTQ inclusivity toolkit. LGBTQ stands for Lesbian, Gay, Bisexual, Transgender, Queer/Questioning.

We are conducting these interviews to learn more about your experience piloting the toolkit during this school year, including how you were involved in using the toolkit, how it was helpful in your/your team’s efforts, and how you think it could be improved for use by other school districts. Your participation is voluntary and you can choose not to participate in a subsequent interview even if you choose to participate in this interview.

Before we begin, I would like to review a few points and confirm whether you consent to participate. These points are also reflected on the copy of the consent statement that I gave you: 

• This interview is completely voluntary. You do not have to take part in this interview. Whether or not you take part in this project will not affect your job or the services your school receives from the district. 

• With your permission, we will audio-record the interview. 

• Your name will not be linked with the notes or audio recording from this interview. No quotes or comments you make will be linked with your name or other personally identifiable information (e.g., your email address) in any way. Your name will not be used in any publications or reports about these interviews. 

• We will only share overall findings from these interviews, and we will protect your identity as a respondent. 

• The information collected in these interviews will be used to help refine the toolkit for potential future use by other school districts.

• You may choose to stop participating in the interview at any time, including skipping certain questions or sections you wish not to answer.

• We expect this interview to take no more than 60 minutes. You will receive a $25 gift card to thank you for participating in this interview. If you decide to stop the interview before we ask all of the questions, you will still receive the gift card.

If you have any questions about the survey or your rights as a participant in this study, you may contact Lisa Carver, ICF Project Manager, at [email protected], or the ICF Institutional Review Board attn. Christine Walrath, at 646-695-8154.

Do you agree to participate?  YES  NO 

Do I have your permission to record the interview?  YES NO 

If yes, continue: Thank you. 

***TURN ON RECORDER***