DOL OWCP DEEOIC Focus Group Consent Form

OMB Control No. 1225-0093

Expiration Date: 02/29/2024

Customer Interviews Consent Form

Informed Consent for Research Participation

Thank you for taking the time to speak with us. Please read the statements below and sign where indicated. By submitting this form, you are indicating that you have read the description of the project and that you agree to the terms as described. If you have any questions, or would like a copy of this consent form, please contact [email protected].

What This Project is About

This focus group is part of a series conducted by the Division of Energy Employees Occupational Illness Compensation (DEEOIC). This project aims at collecting data that will help improve the customer experience while navigating the claims adjudication process.

Your Involvement in the Project

We will ask you questions about your experience with the program including any bright spots or pain points you have experienced during your interactions with DEEOIC. The focus group will take a maximum of 60 minutes.

Your Participation is Voluntary and Confidential

Participation is completely voluntary. You may refuse to answer any questions or end participation at any time. We will take necessary and appropriate precautions to keep what you tell us confidential. While we may develop and present reports that include your anonymous comments and experiences, we will not use names in any of our materials.

Statement of Consent

I have read the above information and received answers to any questions I have asked. I consent to take part in this focus group and to have any information I provide be used in the manner described above. I understand that my name will not be used in connection to my words.

If you agree to participate in this focus group, please sign your first and last name in the box below.