___________________________________________________
I, _________________________________________, agree to take part in this focus group discussion.
I understand that I do not have to be in this focus group. I can leave at any time. I can agree to be in the focus group and then change my 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 to make information about the dangers of trespassing better and easier to understand. I understand that the information is for a report only, and that my name will not be shared with anyone else.
I agree to ask questions about the discussion if I don't understand something. 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 I will be audio recorded during this focus group. I allow CommunicateHealth to transcribe the recording and write a report without my 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 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: _________________________________________
ATSDR is authorized to collect this information by [CERCLA and SARA].
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Sandra Williams Hilfiker |
File Modified | 0000-00-00 |
File Created | 2021-01-25 |