Consent

ATTACHMENT A Informed Consent form rbk 082317.docx

CDC and ATSDR Health Message Testing System

Consent

OMB: 0920-0572

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Attachment A: Informed Consent Form for Pregnant and New Mother Oral Health Focus Groups























Informed Consent Form



Identification of Project

Health Issues Research


Statement of Age of Subject

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 Salter>Mitchell in office at [INSERT LOCATION]:

_________________________.




Purpose

The purpose of this research is to understand health issues facing women who are pregnant or have young children.




Procedures


Study participants will participate in a group discussion that will last approximately 90 minutes.


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 use the research findings in order to develop procedures and communications that may benefit people like me more broadly. I am free to ask questions or withdraw from participation at any time and without penalty.


Contact Information of Investigators

Name: Robert Bailey

Position: Research Director, Salter>Mitchell

Telephone: 703.683.2240

Email: Robert.bailey@saltermitchell.com




Printed Name of Research Participant _____________________________



Signature of Research Participant ________________________________



Date______________________



OMB #: 0920-0572 Exp. 3/3/2018


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