FFG Informed Consent Form

OMB Control No. 0990-0476
Exp. 07/31/2024

Please save a copy
for your records.

FOCUS GROUP PARTICIPANT CONSENT FORM
Study Title:

COVID-19 Public Education Campaign Market Research

Telephone:

571-858-3757 (24 hours)

What is the key information?
You are being asked to participate in a research study to collect information about your thoughts
and behaviors related to COVID-19. This form describes the purpose, procedures, benefits,
risks, and precautions of the information collection. It also describes your right to withdraw at
any time. A member of the project team is available to read this form with you and discuss all
the information if you wish.
This information collection is being done to help better inform researchers of the current
environment related to the COVID-19 pandemic.
What do I need to know about this study?
If you agree to be part of this study, then you will be asked to participate in a focus group where
you will discuss your perceptions and behaviors related to COVID-19. The focus group will last
about 90 minutes and you will be audio and video recorded while you respond to questions. You
do not have to answer any questions that you do not want to.
Other members of the project team and/or members of the sponsoring agency may watch the
session remotely, but they will not interact with the group. People from the project team will take
notes and listen, but they also will not interact with the group. You will only be talking to the
moderator and a small group of other participants.
What are the potential risks of being in this study?
There are minimal risks associated with this study. There is a risk of breach of confidentiality. This
risk is minimized by protections described in the “Who will see the results of this project or my
information?” section below. Please help protect the privacy and confidentiality of others by not
discussing anything from this session outside of the focus group. If you share stories about others
during the focus group, please avoid using real names or other identifying information. The study
staff will work to remove any personally identifiable information from the transcripts of the session.
Does participating in this project provide any benefits?
This study is for research purposes only. Although you may not directly benefit from
participating in this study, other people may benefit because the findings of this study will be
used to inform messaging and public education efforts about COVID-19.
Are there alternatives to participating?
This study is for research purposes only. The only alternative is to not participate in this study.

IRB APPROVED
11/11/2021

Will it cost me anything to participate in the project?
There are no costs to participate in the project. Participants in the focus groups will receive $75
for their participation. You will be paid at the end of your participation in this study.
Do I have to be in this project?
Your participation is voluntary, which means you can stop or withdraw at any time. You may
choose to not participate, or you may withdraw from the study for any reason. There are no
penalties for refusing to participate or leaving the study early.
Your part in the research may stop at any time for any reason, such as if the sponsor decides to
stop the study.
Who will see the results of this project or my information?
The study staff will hear everything you say during the focus group. We will be careful to only let
people working on the project see your information. There is a small risk that others might find
out what you say, despite all our best efforts. In the case of a breach of confidentiality, we will
take steps to notify study participants.
We will audio and video record the focus group, and we will transcribe it. The session may also
be watched remotely by other members of the project team and/or members of the sponsoring
agency. By signing this form, you consent to being audio and video recorded and observed during
the focus group.
Your name and other personal information (for example, contact information like a phone number
and demographic information like gender and race/ethnicity) will not be connected to your
responses, will not be shared with the sponsoring agency, and will not be given out for other
research studies. This means that no one outside of the project team will be able to connect what
you said back to you. The principal investigator, the sponsor or persons working on behalf of the
sponsor, and the Institutional Review Board (IRB) will be able to view and copy confidential, studyrelated records that use your name. This means that we cannot guarantee total confidentiality. As
much as the law allows us to, we will keep everything you share private. This means that we will
not share any information you give us with anyone who is not working on this project—unless we
are required to share that information to protect you or unless we are required by law. However,
if you appear to be a direct threat to yourself or others, we have the right to take action out of
concern for you and others.
All the information we collect including anything you say in the focus group, information collected
during screening, and audio and video files will be stored on a password-protected computer
and/or in locked cabinets that only the project team can access. We will collect some personal
information from you, like your age and race, but we will not collect any information that could be
used to identify you. After three years, we will destroy all the collected information by securely
shredding documents or permanently deleting electronic information. Results from this project
might appear in professional journals or scientific conferences and might be shared with other
project teams. We will not identify any individual participants or link them to the results, and we
will not disclose your identity in any report or presentation.
Whom to contact about this study:
If you have questions, concerns, or complaints about the study, please contact the principal
investigator at the telephone number listed on the first page of this consent document.

Focus Group Participant Consent Form

IRB APPROVED
11/11/2021

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An IRB is an independent committee established to help protect the rights of research subjects.
If you have any questions about your rights as a research subject, and/or concerns or complaints
regarding this research study, contact:
1. By mail:
Study Subject Adviser BRANY IRB
1981 Marcus Ave, Ste 210
Lake Success, NY 11042
2. By calling toll free: 516-318-6877
3. By email: [email protected]
4. By visiting this website: www.branyirb.com/concerns-about-research.
We recognize the topic of COVID-19 may bring up some discomfort. If you need any additional
support, please contact one of the following:
Substance Abuse and Mental Health Services Administration (SAMHSA) Disaster Distress
Helpline
· Call 1-800-985-5990
· Text TalkWithUs to 66746
Suicide Prevention Lifeline
· Call 1-800-273-8255
· Online chat: https://suicidepreventionlifeline.org/ and click “Chat”

Statement of Consent
Please mark one box and sign below. By signing this form, you have not waived any of your
legal rights.
� Yes, I agree to participate in this study. I have read, understand, and had time to think about
all the information above. My questions have been answered, and I have no further questions. I
will receive a copy of this signed and dated consent document.
� No, I do not agree to participate in this study. I have read, understand, and had time to think
about all the information above. My questions have been answered, and I have no further
questions.
_____________________________________________________

Subject’s Printed Name
_____________________________________________________

___________________

Subject’s Signature

Date

Focus Group Participant Consent Form

IRB APPROVED
11/11/2021

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