Consent Form

Study # __________

Incentive: ______

Group: ___________

Time: __________

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:
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Observed (sight and sound); remotely by way of non-public, electronic media. Observers may include CPSC
staff, their agents and guests.
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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.

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Date