Attachment 5 - Respondent Consent Form

Study # __________ Incentive: ______

Group: ___________ Time: __________ Date:__________

Form Approved

OMB No. 0920-1154

Exp. Date: 3/31/26

BANYAN COMMUNICATIONS CONSENT FORM

Please read and sign this sheet before you attend the focus group

We’re pleased you have accepted our invitation to participate.

You will be responding to topics of interest to the Centers for Disease Control and Prevention (CDC). CDC engaged us to recruit for their discussion. The entire focus group will be:

• Observed (sight and sound) virtually via virtual meeting platform. Observers may include CDC staff and our staff.

• Recorded (audio and video) and the audio will be transcribed anonymously for analysis. These transcripts will be the property of CDC. They will not use your voice or image in any public media without your written consent.

This information will not be linked with your name in any way and will not be used for anything except this project. All information from this discussion will be summarized anonymously. We will not sell, distribute, or otherwise release personally identifiable information we collect to CDC unless it is a necessary part of this project. 

In return for your voluntary participation in this project, we will provide a $75 gift card to you for your time spent during the focus group.

Since your opinions, observations, reactions, and other expressions are the reason for conducting this focus group, we hope you will participate fully in the process. You do not have to respond to all questions.

By signing this document, you acknowledge that you understand, agree to, and consent to the above and that you waive and release any claim you may have against Banyan Communications and its clients, owners, agents, affiliates, employees and managers arising out of your voluntary participation in the focus group.

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Sign

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Print Name

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Date

2

CDC estimates the average public reporting burden for this collection of information as 10 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-1154).