Consent

Attachment 13A-1

CONSENT TO PARTICIPATE IN A RESEARCH STUDY

Focus Group Discussions

SMOKE-FREE MULTI-UNIT HOUSING POLICIES STUDY

Please read this consent form carefully and take time to ask the staff as many questions as you would like. Reading this form and talking to the study staff may help you decide whether or not to participate.

Healthy Housing Solutions, Westat, and the Centers for Disease Control and Prevention (CDC) are working to learn how apartment complexes put into place rules about where people can or cannot smoke and how those rules affect residents’ life and health.

We are holding small group discussions with people who live in smoke-free apartment complexes. The purpose of today’s group is to hear residents’ opinions on smoke-free policies in apartment complexes. Your participation will help us learn more about how residents like you have been affected by smoke-free policies. If you agree to take part in this study, we will ask you fill out a brief survey to learn more about you, the housing complex, and your health. Afterwards, we will ask you to take part in a discussion with other residents.

The discussion will be led by a trained staff member. We will discuss topics such as how you decided to live here, how the non-smoking policy was developed, how the policy is enforced, and how you feel about the non-smoking policy. If you do not want to answer a question, you do not have to answer. You may also leave the discussion at any time. The discussion with be audio-taped and transcribed so that the group’s answers can be studied more carefully. Your name will not be included in the transcript.

The survey will take about five minutes and the group discussion will last about an hour. At the end, you will be given a $50.00 Visa gift card.

Your Benefits and Risks from Participation in this Interview

You will not receive any direct benefits from taking part in this study. If you wish, we can give you information on local stop smoking programs for which you may qualify.

Although you may not directly benefit from your involvement in this discussion, your views may help increase understanding of how no-smoking rules can be applied in other communities.

We believe that your participation has few risks. The most significant risk is that you will be asked questions about personal issues in the questionnaire such as smoking habits, health conditions, and feelings about your housing complex. These types of personal questions sometimes may make some people uncomfortable. You do not need to answer any question that makes you feel uncomfortable.

None of the information you share with us will be shared with the management of your apartment complex. Your rent or housing status will not be affected by your participation in this research.

Privacy

Our purpose is to learn more about how residents like you feel about non-smoking policies in apartment complexes. All records will be stored in a locked file cabinet, which only project staff may access.

All information you share will be kept private to the extent allowed by law. Your personal identifying information (name, address, phone number) will be kept separate from your questionnaire responses. All records will be stored in a locked file cabinet or password-protected computer file, which only authorized project staff at Healthy Housing Solutions and Westat may access. Only those staff working on this study will know your name and data.

Your being part of this focus group is voluntary, and you may withdraw your consent and your participation at any time. You will decide whether you want to provide us with this information by being in this study. You are free to choose not to be in this study. It is up to you.

You may ask questions about the information on this form or about the study in general at any time. You may contact Carol Kawecki, Healthy Housing Solutions, at 301-524-5078 or 877-312-3046.

If you have questions about your rights as a research participant, you may contact the Westat Institutional Review Board Administrator, Sharon Zack. She can be reached by calling 800-937-8281, ext. 8828.

STATEMENT OF CONSENT

I have read the consent form. My questions have been answered. I consent voluntarily to participate in this research study and I will receive a copy of this consent form for my records.

I am not giving up any legal rights by signing this form. Nothing in this is intended to change any applicable federal, state, or local laws.

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Name of Participant (Print) Signature Date

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Name of Person Obtaining Signature Date

Consent