0920-20PT Consent Form_Consumer

Consent Form for Participation in a Consumer Focus Group

Introduction and Purpose:

You have been asked to take part in a consumer focus group that is being conducted by KRC Research and GC Global Research for the Centers for Disease Control and Prevention (CDC). Your participation in this activity is voluntary. If you agree to participate, we ask you to read and sign this consent form. You may withdraw your consent to participate, for any reason, at any time.

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.

Details about this study are discussed in the following sections. It is important that you make an informed choice about participating. You should ask the study personnel any questions you have at any time.

Important points to consider before consenting to participate:

• Rights Regarding Participation: This discussion is completely voluntary. If any questions make you feel uncomfortable, you may choose not to answer.

• Privacy: We will take every precaution to protect your identity and ensure your privacy unless required by law. We will keep your name and identifying information private and your identity will not be disclosed, nor included in any reports. Your contact information and name will not be attached to any of your responses.

• Benefits: Your participation in the focus group will not result in any direct benefits to you. However, your input will help to develop effective communication materials.

• Risks: The focus group poses minimal, if any, risks to you.

• Incentive: In appreciation of your time, you will receive an incentive of $75 for participating.

• Audiotaping and Notes: The discussion will be video and audio recorded. No quotes or comments you make will be linked with your name in any way. We will keep all information, notes, and audiotapes stored securely. Only project staff will be able to access the information. These notes and audio recordings will be destroyed upon conclusion of the project.

• Observers: Project staff may listen in on the focus group and take notes. They will not be joining the discussion and they will not identify you by name in their notes.

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

• Contact Information: If you have any questions about this discussion or the activity specifically, please contact Molly Dowling, Contracting Officer’s Representative, at (404) 639-8332 or gpi7@cdc.gov.

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

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Signature of Participant Date

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Signature of Person Obtaining Consent Date