Form 0920-18AFX Focus Group Consent

Attachment 6. Focus Group Consent Form

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

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Informed Consent for Focus Groups

The Centers for Disease Control and Prevention (CDC) is conducting a formative research study exploring clinician experiences with the diagnosis, treatment, and management of traumatic brain injury (TBI) in rural settings. This study is authorized by Section 301 of the Public Health Service Act (42 U.S.C.241), which provides the legislative means for CDC to conduct research to advance public health across the lifespan and to reduce health disparities. CDC is collaborating with the Walsh Center for Rural Health Analysis at NORC at the University of Chicago (NORC)—a not-for-profit research organization—to conduct this study.

You are being asked to participate in this discussion based your experiences providing care in your rural community. The CDC will use the information gained from these focus groups to create educational and outreach programs to reduce disparities between urban and rural communities in TBI diagnosis and management. The focus group should take approximately 90 minutes. There are no foreseeable risks to your participation. Your open and honest opinions are appreciated; participation is voluntary; you may choose to not answer a question; and you can leave at any time. If at any point during the focus group you wish to withdraw as a participant, please notify the Facilitator. Note, however, that your previous responses will remain part of the record. Whether or not you choose to participate in the focus group, or decide to withdraw at any point, will not affect you in any way. Your open and honest opinions are appreciated; participation is voluntary, you may choose to not answer a question, and you can leave at any time.

Please be advised that while the information you provide will not be made publically available, the CDC may report the results of the focus group in aggregate. While we will not use your individual name with your responses, we may reference other information, such as the census region where you practice or type of organization in which you practice. If you have any questions about the study at a later point you may contact the project director, Alana Knudson, at 301-634-9326. If you have questions about your rights as a participant in this research project, please call the NORC Institutional Review Board Administrator at 866-309-0542.

“I have read and understand the information presented in this document, and have been given the opportunity to ask any questions. I give my permission to be recorded using audio equipment during this research study. I understand that the recordings will be reviewed for the purposes of this study and destroyed shortly thereafter. I freely choose to participate in this research study, and understand my right to withdraw as a participant at any time.”

Print name

of participant:___________________________________________ Date______________

Signature

of participant: ___________________________________________ Date______________

Signature of individual

Obtaining consent:________________________________________ Date______________

Rural Disparities in Traumatic Brain Injury | 2