DEI Focus Group_Consent Form

Study # __________
Group: ___________

Time: __________

Incentive: ______
Date:__________

OMB Control No: 3041-0136; Expiration date 01/31/2024

FIELDWORK CONSENT FORM
Please read and sign this before you participate
We’re pleased you have accepted our invitation to participate.
You will be participating in a focus group regarding a number of topics of interest to the U.S. Consumer
Product Safety Commission (CPSC), who have engaged us to host their session. The entire focus group
will be:
●

Observed (sight and sound); remotely by way of non-public, electronic media. Observers may
include CPSC staff, their agents and guests.
●
Recorded (audio and video). This record will be the property of CPSC and will be theirs to use as
they see fit. They will not, however, use your voice or image in any public media without your written
consent.
In return for your voluntary participation in this research, our client will reimburse you through us. This
relationship constitutes an Independent Contractor relationship, not an Employment relationship. Any
ideas you express during the focus group become the property of our clients to use without restriction for
which no further reimbursement is owed to you.
Since your opinions, observations, reactions, etc. are the reason for conducting this focus group, we hope
that you will participate fully in the process. You should know, however, that you are under no obligation
to do or say anything during the focus group. If you choose not to respond to a line of questioning, not to
partake in a given activity or not to volunteer certain information, that is your prerogative.
You acknowledge that the session you will be participating in is confidential in nature and you agree not
to disclose any information concerning this session or use it after the session.
You further acknowledge that pursuant to Fieldwork’s privacy policy, we will not sell, distribute, or
otherwise release personally identifiable information we collect to our clients unless it is a necessary
component of this research project. We will not sell, distribute or otherwise release personally identifiable
information we collect to other parties.
If you have provided your wireless phone number to Fieldwork you agree that Fieldwork and its clients
may call and send text messages for project related purposes. You may revoke your consent at any time.
By signing this document, you acknowledge that you understand and agree to the above and that you
waive and release any claim you may have against Fieldwork and its clients, owners, agents, affiliates,
employees and managers arising out of your voluntary participation in a focus group.

_______________________________
Sign
_______________________________
Print Name
_______________________________
Date