0920-0572 ATSDR-Message-Testing_Attachment-8_Consent-Form

Form Approved

OMB No. 0920-0572

Exp. Date: 2/28/2015

ATSDR Task Order 15 Message Testing

Attachment 8

Consent Form¹

___________________________________________________

I, _________________________________________, agree to take part in this focus group.

I understand that I do not have to be in this study. I can leave at any time without penalty. I can agree to be in the study and then change my mind later.

I allow the Centers for Disease Control and Prevention (CDC) to use the information from this study.¹ I understand that the information is for research only, and that my name will not be shared with anyone else.

I agree to ask questions about the study if I don't understand something. If I have questions after the study is over, I can contact Perrie Briskin at perrie@communicatehealth.com or at 413-582-0425.

Audio Recording

I understand that I will be audio recorded during this study. I understand the recording will not be transcribed. I allow CDC to use the recording to help them write a report without my name for research purposes. I understand that the recording will be destroyed and my name will not be used for any other purpose.

Summary

I have read and understood this consent form. I understand that I will get a copy of this form.

Print Name:         _________________________________________

Signature:           _________________________________________

Date:                   _________________________________________

1 The ATSDR is authorized to collect this information by [CERLA and SARA].