0920-1154 CONSENT FORM In-Depth Interviews with Hispanic or Latina

Form Approved

OMB Control No.: 0920-1154

Expiration date: 3/31/2026

CONSENT FORM

In-Depth Interviews with Hispanic or Latina Women

July 13, 2023 DRAFT

TO BE REVIEWED AND SIGNED BY PARTICIPANT AND RECRUITER PRIOR TO INTERVIEW

Introduction and Purpose:

You have been asked to take part in an interview that is being conducted by KRC Research on behalf of the Centers for Disease Control and Prevention (CDC). Your participation in this interview is voluntary. If you agree to participate, we ask you to read and sign this consent form. You may withdraw your consent to participate, for any reason, at any time.

You are the expert on your experience, and your thoughts and opinions are greatly valued and appreciated. We want to learn from you. We encourage you to speak openly and honestly about your experience. There are no right or wrong answers.

Details about this project are discussed in the following sections. It is important that you make an informed choice about participating. You should ask the interviewers named below any questions you have at any time.

Should you agree to participate in the discussion, here are some points you should know:

• Rights Regarding Participation: This discussion is completely voluntary. If any questions make you feel uncomfortable, you may choose not to answer.

• Privacy: We will take every precaution to protect your identity and ensure your privacy. We will keep your full name and identifying information private and your identity will not be disclosed, nor included in any reports. Your contact information and name will not be attached to any of your responses.

• Benefits: Your participation in the interview will not result in any direct benefits to you. However, your input will help to develop effective communication materials that aim to protect people’s health.

• Risks: The interview poses minimal, if any, risks to you.

• Incentive: You will receive $75 as a token of appreciation for your participation.

• Audio and Video Recordings and Notes: The discussion will be audio and video recorded so it can be transcribed and used to help write a report. However, no recordings will be shared with CDC; they will only be used by the interviewing team. Transcripts based on the recordings will be shared with CDC, but these transcripts will not include your name or any identifying information. No comments you make will be linked with your name in any way in reports about these interviews.

We will keep all information, notes, and audio recordings stored securely. Only project staff will be able to access the information. Project records will be maintained in accordance with the federal record retention requirements.

• Being on Camera: We ask that you not join the meeting on a device such as a laptop, tablet, or smartphone where you can be on camera with the interviewer. During the interview, we also request that you send calls to voicemail and do not do other activities on our device to ensure the conversation is free of distractions.

• Questions: We will answer any questions you have about this interview.

• Contact Information: If you have any questions about this discussion or the project specifically, please contact Mike Ruddell at [email protected].

Your Consent

I have read this consent form. I had a chance to ask questions, and my questions were answered. I was given a copy of this consent form. The above document describing the benefits, risks, and procedures for this project has been explained to me. I agree to participate in the project.

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Signature of Participant Date

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Signature of Person Obtaining Consent Date

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 Reports Clearance Officer, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA 0920-1154