consent form

Focus Group Participant Informed Consent Form

Kazakhstan Dairy Consumption and Agricultural Practices

Staff from the United States National Cancer Institute (NCI) are working with the Semipalatinsk State Medical Academy to learn more about the activities of daily life in Kazakhstan during the time of the nuclear testing from 1949-1962.

You will be taking part in a focus group interview. A focus group interview is a group discussion where we ask you to recall and describe events that took place between 1949 and 1962. You will be asked about dairy products that people ate and drank, daily activities of children in your village, living conditions, and how dairy animals were tended in your village. There will be up to 8 people participating in the group. There are no right or wrong answers, we just want you to try to recall as best you can and also give us your opinions about dairy products that people ate and drank and agricultural practices at that time.

Your participation in this group discussion is voluntary and you may ask to stop at any time. Your participation and any comments you make will be kept private to the extent permitted by law. Comments from all people taking part in these discussions will be combined in a summary report that will not identify any one person. This group discussion will last two hours.

What you say will be recorded on paper forms by a note-taker and on an audio recording device. Your name will not appear on any forms and information about your personal information will not be connected to your remarks in any way. We will be audio recording this focus group in order to more easily prepare our summary report. The audio files will be destroyed after the study is complete. You will be paid $5.00 for taking part in this group discussion.

There are no physical risks to you from taking part in this group discussion other than those you would have in daily life. You do not have to be in this study. It’s okay to stop even after we begin. There will be no bad feelings. No one will be angry or upset with you. There are no direct benefits to you from participating in this group discussion.

Please ask as many questions as you need to make sure you understand this study before you sign this form.

If you have any questions later about the study, you may call Dr. Zhaxibay S. Zhumadilov with SSMA at 7-3222-561604.

If you have any questions about your rights as a study participant, you may call SSMA’s IRB Chairperson, Dr. Raifa L. Ivanova, at 7-3222-531891.

If you decide you want to be in this study, please print and sign your name.

With my signature below, I agree that this information has been explained to me, I understand my role in the group discussion, and I agree to take part in this group discussion and its audio recording.

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Print your name here Date

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Sign your name here Date

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Moderator print your name here Date

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Moderator sign your name here Date

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