Consent form

LTG Associates, Inc.
Individual Interview Informed Consent
AGREEMENT TO PARTICIPATE IN AN INTERVIEW
You are being invited to be interviewed for a project that is being conducted by LTG Associates, Inc. (LTG). The purpose of this consent
form is to help you decide if you want to participate in an individual interview. Please read this form and the description of the project
carefully. To be in this interview you must give your informed consent. “Informed consent” means:
▪ Reading this consent form;
▪ Asking questions about anything that is not clear to you; and
▪ If you agree to be interviewed, signing the consent electronically and returning it.
You should not agree to be interviewed until all of your questions have been answered.
Background Information
Project name: Office on Women’s Health Campaign to Increase Postpartum Depression Symptom Reporting
Project goals: (1) To understand your thoughts and feelings about the postpartum depression campaign materials that you reviewed
in a recent focus group; (2) To understand ways to make the campaign materials better; 3) To understand problems with the campaign
materials.
Project description: The Office on Women's Health (OWH), part of the U.S. Department of Health and Human Services (HHS), works
to improve the health and sense of well-being of all U.S. women and girls. Helping moms seek care for conditions that affect new
moms, such as postpartum depression, is part of that mission. OWH has asked LTG Associates to create a media campaign to raise
moms’ awareness of the signs of postpartum depression and encourage them to seek care from a health care professional. This can
include things like posters, a website, and TV segments.
Interview Purpose
The purpose of this interview is for LTG to understand the things that can make the materials for the postpartum campaign better.
Learning about your views and experiences will help us do this. During the group discussion, we were able to speak to many moms
about how they felt about the materials. We are now interviewing some of the moms from those focus groups so we can hear in
greater detail about what you did and did not like about the materials. The results of this interview will help us make changes to the
materials so they can better help moms who are experiencing postpartum depression and encourage them to get care.
Your Involvement
You are being asked to participate in this interview because you participated in a group discussion about the campaign materials. Your
participation in this activity is completely voluntary. You do not have to do it if you do not want to, and you are not required to answer
any questions you do not wish to answer. You can take back your agreement to participate in this interview at any time without any
problem.

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Interview Description
This interview is expected to last approximately one hour. The interview will be conducted by someone who is trained in doing these
types of interviews. The interviewer will ask you to talk about your views and experiences. The interview will be recorded. After the
interview is over, the recording will be transcribed to provide information for accuracy in our analysis.
Confidentiality
The information we collect from this interview will remain confidential. This means that the fact that you participated in an interview
will not be revealed to anyone other than the person who conducted the interview. We protect the confidentiality of your answers by
assigning a code number to your information. We only refer to this number and not your name when we analyze the information and
discuss the results in any written reports. All the information that we get from the interview will be kept in a locked and secured place
to which only appropriate project staff have access.
Because the interview is part of a project receiving funding from the Office on Women’s Health (OWH), OWH staff members could
have access to some of the information and/or records resulting from this project. However, none of the information that LTG will
provide to OWH staff members will have any identifying information. Within the bounds of our contract and applicable rules and
regulations, we will do our best to ensure the strict confidentiality of all personally identified information. The government has the
right to all information arising from this work. However, their interests would not be served to have identified data from the interviews
we are conducting as they reasonably believe that they would not get good information from respondents like you.
Risks and Discomforts
We do not think that being a part of this interview will cause you any physical or psychological harm beyond what you might face in
everyday life. We will not be asking personal questions. However, since the materials are about postpartum depression, it could create
some discomfort. If you are uncomfortable answering a particular question, you are free not to answer the question. You are also free
to stop the interview at any time.
Benefits for You
The only possible benefit to you in participating in this interview is that it may help OWH to help moms who may have symptoms of
postpartum depression.
Costs and Incentives
Your participation in this interview will not cost you anything. You will receive an honorarium of $75 for participating in this interview.
Questions or Concerns
You have the right to ask any questions you may have about this project. If you have questions, complaints, or concerns, or believe
you may have developed an injury or had a traumatic event related to your interview, please contact Nathaniel Tashima Human
Protections Administrator, by email at ntashima@ltgassociates.com or by phone at (301) 270-0882.
If you have questions regarding your rights as a participant or you have concerns or general questions about the project or your
interview, please contact Cathleen Crain by email at info@ltgassociates.com or by phone at (301) 270-0882.

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Signature and Consent to participate in the Interview
Before deciding whether to participate in this interview you should have:
▪ Read this consent form
▪ Asked questions about anything that is not clear.

I understand the interview described above. I agree to participate in this activity.

Print Name of Participant

Signature of Participant

Date

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