Consent Form

Attachment H: Focus Group Consent Form

FOCUS GROUP DISCUSSION CONSENT FORM

Purpose:

The purpose of this focus group discussion is to gain participants’ opinions and beliefs about possible concepts, ideas, and materials that will be used in the Health Hazard Evaluation (HHE) Program, a part of the Centers for Disease Control and Prevention (CDC)/National Institute for Occupational Safety and Health (NIOSH). This information will be used to create influential and effective messages that will be used in the HHE Program, which aims to reduce workplace health hazards and their resulting illnesses and injuries throughout the United States.

Focus Group Procedures:

Participation in this focus group is voluntary. If you decide to participate you will be asked questions about your attitudes and opinions about different messages and deliverables that will be used by the HHE Program. This focus group discussion will take approximately 2 hours. Participants may decide to not participate at any time during the discussion and will not be penalized in any way for doing so.

Confidentiality:

This focus group discussion will be audio taped for use by the lead investigators. Notes on the discussion will also be taken today by observers for use in this research study. Your name and identifying information will not be saved with the audio tapes to ensure that your name cannot be matched to your comments. Only the research team will have access to the tapes and notes. All information you provide will be secure. Your comments will be used by CDC/NIOSH for research, education, or training purposes only. Your comments will not be used for any commercial or public activities.

Potential Benefits of Involvement in this Study:

Information gained from this focus group discussion will be used by the research team to gain valuable insight about your thoughts and opinions of the messages and mediums used by the program. This will enable the research team to create effective messages and dissemination methods to be used by the program. You will benefit from engaging in an interesting discussion with others and will have the chance to voice your opinion. After the discussion, you will receive a stipend of $75.00.

Potential Risks of Involvement in this Study:

Participation in any research study has potential risks, but they are minimal for this study. Participants may feel uncomfortable answering certain questions or sharing their opinions, but no one will be asked to reveal personal information. We can’t guarantee that you will feel comfortable answering every question we ask or in sharing your opinions with us, but please let us know if you experience any discomforts during the focus group discussion. If at any point during the discussion you feel uncomfortable, please let us know; we may be able to clarify or explain why we asked the question.

Participant Rights:

You have the right to choose whether or not to participate in this research study. Your participation is voluntary. If you choose not to participate or withdraw before the end of the study you will face no penalties.

Contacts:

For questions or concerns regarding this research study or the focus group discussion, please contact _________________ at ___________________.

If you choose to participate, please read the statement below and sign:

I have read the above statement of informed consent and fully understand the purpose and processes of this research study. I understand that I will receive a copy of this informed consent form to keep for my own records. I understand that if I have any questions or concerns regarding this study I should contact the person listed above. I have chosen to participate and fully understand that I can withdraw from the focus group discussion at any time if I wish to do so.

Printed Name:___________________________________________

Signature:_______________________________________________

Date:___________________________________________________