Att 6_ Consent Form: Parents of Tween

ATSDR Task Order 15-4 Storyboard Testing

Attachment 6

Consent Form: Parents of Tween Participants¹

___________________________________________________

I, _________________________________________, agree to let my child ________________ take part in this focus group discussion.

I understand that ______ [child’s initials] does not have to be in this focus group and can leave at any time. ______ [child’s initials] can agree to be in the focus group and then change his/her mind later with no consequences or effect for not participating.

I allow the Agency for Toxic Substances & Disease Registry (ATSDR) to use the information from this discussion. I understand that the information is for a report only, and that ______ [child’s initials] name will not be shared with anyone else.

I agree to ask questions about the discussion if I don't understand something that ______ [child’s initials] is being asked to do as part of this focus group. If I have questions after the focus group is over, I can contact Mary Ann Petti at maryann@communicatehealth.com or at 413-582-0425.

Audio Recording Release

I understand that ______ [child’s initials] will be audio recorded during this focus group. I allow CommunicateHealth to transcribe the recording and write a report without ______ [child’s initials] name to improve the materials. I understand that CDC and ATSDR will not have access to the audio recordings. I understand that the recording will be destroyed and ______ [child’s initials] 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:                   _________________________________________