Case Study Consent Form

AttL_CSConsent.pdf

[NCSTLTPHIW] Information Collections to Advance State, Tribal, Local and Territorial (STLT) Governmental Agency System Performance, Capacity, and Program Delivery

Case Study Consent Form

OMB: 0920-0879

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Attachment L. Case Study Consent Form
Model Aquatic Health Code (MAHC) Use and Implementation Case Study
Please read and sign this sheet before you attend the interview
We’re pleased you have accepted our invitation to participate in this interview. Your participation will help
CDC understand how the MAHC is meeting the needs of recreational water programs across State,
Territorial, Local, and Tribal health departments in the United States.
The entire interview will be recorded (audio and video) and the audio will be transcribed anonymously for
analysis. These transcripts will be the property of CDC. We 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 value your opinions and reactions and hope you will participate fully and openly. You do not have to
respond to all questions.
By signing this page, you acknowledge that you understand, agree to, and consent to the above
statements prior to participating in the interview.

_______________________________
Sign
_______________________________
Print Name
_______________________________
Date


File Typeapplication/pdf
File TitleMicrosoft Word - AttL_CSConsent
Authorxlq2
File Modified2024-07-18
File Created2024-07-18

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