Consent Form

Attachment 4 – Consent Form

Hand Hygiene Focus Group Discussion Consent Form

Introduction and Purpose:

[CONSULTING COMPANY] is conducting focus groups with men and women to learn about opinions of hand hygiene behavior and preferences for health information. Focus group findings will be used to help develop a health communication campaign focused on handwashing behaviors. We expect this focus group to take about 90-minutes. In the focus groups we will discuss hand hygiene behavior when in contact with food, after use of the bathroom, as well as your preferences for health information.

You are the expert on your experience, and your thoughts and opinions are greatly valued and appreciated. We want to learn from you. We encourage you to speak openly and honestly about your experience. There are no right or wrong answers. Should you agree to participate in the discussion, here are some points you should know:

• Rights Regarding Participation: This discussion is completely voluntary. You may choose to leave the focus group and/or not answer a question at any time for any reason.

• Privacy: We will take every precaution to protect your identity and ensure your privacy unless otherwise determined by law. We will keep your name and identifying information private. Your contact information will be kept separate from any focus group responses and all responses will be summarized anonymously. We also will never use your name in any reports.

• Benefits: Your participation in the focus group will not result in any direct benefits to you. However, your input will help to develop a communication campaign for hand hygiene behavior.

• Risks: The focus group poses minimal, if any, risks to you. None of the questions are of a sensitive nature, so none of them should make you uneasy.

• Incentive: In appreciation of your time, you will receive a gift of $40 for participating in today’s focus group.

• Audiotaping and Notes: The discussion will be audio-recorded. No quotes or comments you make would be linked with your name in any way. We will take notes throughout the focus group today to help us keep track of your responses. These notes and audio recordings will be destroyed upon conclusion of the project. We will keep all information, notes, and audiotapes locked in a file cabinet or a secure computer file. Only study staff will be able to access the information.

• Observers: Individuals from the study team will be observing this focus group silently. They will not participate in the discussion.

• Questions: We will answer any questions you have about this focus group discussion before you take part.

• Contact Information: If you have any questions about this discussion or the communication campaign, please contact [INSERT POINT OF CONTACT AT CONSULTING FIRM].

Your Consent

I have read this consent form. I had a chance to ask questions, and my questions were answered. I was given a copy of this consent form. I agree to participate in the study.

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The above document describing the benefits, risks, and procedures for this research study has been explained to me. I agree to participate.

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Signature of Participant Date

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Signature of Person Obtaining Consent Date