HMTS 7-06 - Attachment X - Consent Form

Nutrition and Eating Focus Group

Participant Consent Form

About the Project

We have asked you to join a focus group talk with 7 or 8 other people. You will help public health planners understand what Americans think about choosing and eating foods for a healthier diet. The talk will last about 1 ½ to 2 hours. A trained leader will conduct it. The results will help public health planners design a health campaign.

We will record this talk by audiotape. Also, members of the project team will watch the tapes and write down what is said. We do this so we can write a report about the focus groups. We will not allow anyone outside this project to see or listen to the recordings. The tapes will be kept in a locked cabinet. We will destroy the tapes by (insert date 12 months from date of focus group). We will write a report based on the results of this and other focus groups, but will not use your name in any reports or publications resulting from the focus group discussion. These reports may be shared with other public health planners. We will make transcripts of the focus group discussion, and we will delete your name from the transcripts. All that you say will be kept private to the extent permitted by law.

We do not foresee any risks to you from participating in this study. Your participation is voluntary, and you do not have to answer any questions or discuss any issues that you do not want to discuss. You may stop at any time without penalty.

This project is sponsored by the Centers for Disease Control and Prevention. If you have any questions about this project, please call Reba Griffith at 770-488-5548.

If you have questions about your rights as a participant in this project or think you have been harmed, please call 1-800-584-8814. Leave a message with your name and phone number, and someone will call you back as soon as possible.

We thank you for your time.

Nutrition and Eating Focus Group

Participant Consent Form

My signature verifies that I have read the About the Project and understand my rights as a participant. I agree to participate in today’s discussion. I understand that the group will discuss nutrition and eating. I agree to being audio-taped and observed. I understand that only the people working on this project will be given access to the audio-tape and transcription. I understand that CDC does not plan to use my name or any other identifying characteristic in any report or other products that may result from this project.

Signature: ________________________________________________________

Name (Please print): ________________________________________________

Date: ___________________________