0920-0800 Attachment C2 Consent Form Example

Appendix C2

Example of a Consent Form

Participant Consent Form

About the Project

You are invited to participate in a focus group talk with up to (insert number of planned participants). Your participation will help public health planners understand what the general public thinks about (insert specific cancer). The talk will last about 2 hours. A trained leader will lead the discussion. The results will help public health planners design a health campaign. Combined results from today’s discussion might be shared with the public through a journal publication.

We will audio record this discussion. Members of the project team will listen to the tapes and write down what is said. Individual names will not be included in the written notes. We do not plan to allow anyone outside this project to listen or read anything that is recorded. All that you say will be kept secure to the extent permitted by law. Your name will not be used in any reports or publications resulting from the discussion. We will make transcripts of the discussion and we will delete your name from the transcripts. The DVDs will be kept in a locked cabinet. We plan to destroy the DVDs by (insert date 12 months from date of discussion).

We do not foresee any risks to you from participating in this study. Your participation is voluntary and you do not have to answer any questions or discuss any issues that you do not want to discuss. You may stop participating at any time.

This project is sponsored by the Centers for Disease Control and Prevention. If you have any questions about this project, please call (insert name) at (insert telephone number).

If you have questions about your rights as a participant in this project or think you have been harmed, please call 1-800-584-8814. Leave a message with your name and phone number, and someone will call you back as soon as possible.

Thank you for your time.

Participant Consent Form

My signature verifies that I have read the About the Project and understand my rights as a participant. I agree to participate in today’s discussion. I understand that the group will discuss (insert specific cancer). I agree to be audio-taped and observed. I understand that only the people working on this project will be given access to the audio-tape and transcription. I understand that CDC will not use my name or any other identifying characteristic in any report or other products that may result from this project.

Signature: ________________________________________________________

Name (Please print): __________________________________________________

Date: ___________________________