Attachment D- Revised Consent Form

Informed Consent Form

OMB No.: 0925-0645

Expiration Date: 12/31/2014

Collection of this information is authorized by The Public Health Service Act, Section 411 (42 USC 285a). Rights of study participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be kept private to the extent provided by law. Names and other identifiers will not appear in any report of the study. Information provided will be combined for all study participants and reported as summaries. You are being contacted by advertisement and have chosen to contact us to complete this instrument so that we can explore motivations for engaging in physical activity.

Public reporting burden for this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0645). Do not return the completed form to this address.

Identification of Project	Goals and Values in Physical Activity
Purpose	The purpose of this research is to explore motivations for engaging in physical activity.
Procedures	Participants will complete a survey, and then participate in focus groups. The survey includes similar demographic questions that were posed during the screener and a brief set of items to assess typical exercise behavior patterns of respondents and level of interest in being physically active on a regular basis. Participants will then be asked about their values and goals, independent of and related to physical activity, in a focus group setting. The total time involved, including instructions, will be no more than 100 minutes.
Confidentiality	All information collected in this study will be kept secure to the extent permitted by law. I understand that the data I provide will be grouped with data others provide for the purpose of reporting and presentation and that my name will not be used. I understand that the session will be audiotaped, but my face will not be videotaped. My voice recording will not be played to others besides the research team without my written permission. The recordings will be kept in a locked cabinet and will be destroyed by December 31, 2016.
Risks	I understand that the risks of my participation are expected to be minimal in nature.
Benefits, Freedom to Withdraw, & Ability to Ask Questions	I understand that this study is not designed to help me personally but that the investigators hope to gain a better understanding of how values and goals relate to physical activity. I am free to ask questions or withdraw from participation at any time and without penalty. You will receive $30 as a thank you after you have completed the study.
Statement of Age of Subject Contact Information of Investigators	I state that I am at least 18 years of age, in good physical health, and wish to participate in a program of research being conducted by the Health Behaviors Research Branch at the National Cancer Institute, Rockville, MD 20852. If you have any questions about this study, please contact: Heather Patrick, PhD Program Director, Health Behaviors Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute Telephone: 240. 276.6795 Email: patrickha@mail.nih.gov If you have any questions about your rights as a participant in this study, please call the Westat Human Subjects Protections office at 1-888-920-7631.

Printed Name of Research Participant _____________________________

Signature of Research Participant ________________________________

Date______________________