Consent Form - FG

Attachment 5 - Respondent Consent Form_FG.docx

[OS] CDC/ATSDR Formative Research and Tool Development

Consent Form - FG

OMB: 0920-1154

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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 platform. Observers may include CDC staff and our staff.

  • Recorded (audio and video). The audio recording will be the property of CDC. CDC will protect your privacy and confidentiality, and none of your personally identifiable information will be released.

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. The risks of participating in the focus group will be minimal. You do not have to respond to any questions you don’t want to answer.


We will not sell, distribute, or otherwise release personally identifiable information we collect to CDC.

By signing this document, you acknowledge that you understand, agree to, and consent to the above.



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Sign


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Print Name


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Date



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