Respondent Consent Form (24CU)

Form Approved

OMB No. 0920-1154

Exp. Date: 3/31/26

Attachment 5 - Respondent Consent Form

PARTICIPANT CONSENT FORM

Please read and sign this sheet before you attend the interview/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 interview/focus group will be:

• Observed (sight and sound) virtually via a web conference platform, such as Zoom. Observers may include CDC staff and our staff.

• Recorded (audio and video). This recording will be the property of CDC. They will not use your voice or image in any public media without your written consent.

In return for your voluntary participation in this project, we will provide a [$350 for MDs/ $250 for non-MDs] gift card to you for your time spent during the interview/focus group.

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

We will not sell, distribute, or otherwise release personally identifiable information we collect to CDC unless it is a necessary part of this project.

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 interview/focus group.

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Sign

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Print Name

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Date