Attachment 28. Consent Form English_10.23.23

Attachment 28. Consent Form – English Participant consent form for conversation groups

Participant Consent Form for [Online/In-Person] Conversation Groups

CDC Women’s Health Study

Thank you for your interest in participating in the study described below. This consent form explains the purpose of the study we are conducting. Please read it carefully. If you have any questions, you may ask the conversation group facilitator or a member of the study team before you sign the consent form. If you do not have questions now but have questions that arise later, you may ask those questions at any time before, during, or after the session.

Privacy Act Statement

The information you are being asked to provide is subject to the Privacy Act and is covered by the System of Records Notice (SORN) 09-20-0136, “Epidemiologic Studies and Surveillance of Disease Problems”.  Providing this information is voluntary.  The principal purposes for which CDC will use the information that you provide for the CDC Women’s Health Study are to (1) understand folic acid and fortified food awareness, as well as food and supplement use practices, (2) develop new messaging and communication products to improve knowledge, awareness, and practices, and (3) inform future intervention activities to prevent neural tube defects among Hispanic/Latina women of reproductive age.  The information that you provide for the KAPs Women’s Health Study will only be used to conduct the project. The information you provide will be maintained in a Privacy Act system of records and will be used and may be disclosed for the purposes and routine uses as described and published in the aforementioned SORN which can be found at: www.hhhs.gov/foia/privacy/sorns/09200136/index.html

1. What is this study about?

This study is being conducted by EurekaFacts and is sponsored by the Centers for Disease Control and Prevention (CDC). We are recruiting Spanish-speaking Hispanic/Latina women (18 years and older) to join in small group conversations to talk about your thoughts, feelings, and experiences with women’s health. The information we learn from the small group conversations will help CDC find ways to talk with Hispanic/Latina women about their health and the role that culture plays in their health choices.

2. Where will the conversation session take place?

[ONLINE: The session will be held online using Zoom. A EurekaFacts staff member will contact you about the scheduled date and time. The link to the Zoom session will be provided with the confirmation email for participation.]

[IN-PERSON: The session will be held in person at a location near you. A EurekaFacts staff member will contact you about the scheduled date and time. The address will be provided with the confirmation email for participation.]

3. What will happen during the session?

During the sessions, you and other participants will talk about their thoughts and experiences as Hispanic/Latina women living in the United States, particularly as it relates to health. A trained moderator will facilitate the sessions to cover topics related to Hispanic/Latina women’s health and the role that culture plays in their health choices. Topics of conversation include:

• Experiences as Hispanic/Latina women and cultural influences

• Experiences with health care providers and conversations of pregnancy

• Experiences with food and vitamin choices

We will also share information about Hispanic/Latina women’s health and get feedback to improve this information.

All sessions will be held completely in Spanish. There will be no sessions in English.

4. Will information be kept private?

Yes, all information shared in conversation groups will be kept confidential. You will be assigned a unique identifier (ID) and your name will not be linked to their answers. All information provided by you and other participants may be used only for the study purposes and may not be disclosed, or used, in identifiable form for any other purpose except as required by law (20 U.S.C. §9573 and 6 U.S.C. §151). All sessions will be recorded and used solely for analysis purposes; no identifying information will be shared in our report.

5. How long will the session last?

Each conversation group will last about 90 minutes.

6. Is there an incentive for participating?

Yes. After the session, you will receive $75.00 from a major credit card company. An e-gift card will be provided for online participation and a physical gift card for in-person participation.

[ONLINE: Please allow 7-10 business days for processing the e-gift card. The e-gift card will be sent via email from Virtual Incentives. Please check your Spam or Junk folder. Also, please note that the virtual incentives expire after 6 months.]

7. What are the possible risks of being in the study?

There are no known risks to participating in this voluntary study, but you might feel uncomfortable talking about health experiences.

8. Who can I contact with questions or for further information?

If there are any questions about the study, please contact Esther Cortez at corteze@eurekafacts.com or call 202-794-8199. If there are questions about study participant rights, please review at EurekaFacts Privacy Policy for details on our policies and procedures.

9. Can I choose to end my participation at any time?

Participation in a session is completely voluntary. You have the right to refuse to answer any questions and may decide to leave at any time. If you choose to leave early, we may need to reduce the gift card amount so that it is proportional to the level of participation.

• I have read the above consent form and all my questions have been answered. I agree to participate in this conversation session.

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By signing below, you agree to participate in this conversation session. You will receive $75.00 e-gift card from a major credit card company at the end of the session. You understand that the $75.00 will be processed 7 to 10 business days after the session has ended.

Your signature below will indicate that you have read and understood the information provided above and your questions have been answered satisfactorily.

Name (print/ type): _________________________________________________________________

Signature: _________________________________________________

Date: _______________________

Email address: _________________________________________________________________ (Emails will be used for the purposes of e-gift card delivery.)