Consent Form

Focus Group Consent Form

Introduction and Purpose:

KRC Research is conducting focus groups to hear their opinions about a healthcare topic. We expect this conversation to take up to 90 minutes.

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 conversation, here are some points you should know:

• Rights Regarding Participation: This conversation is completely voluntary. You may choose to leave the discussion 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 required by law. We will keep your name and identifying information private, and your identity will not be disclosed, nor included in any summary reports. Your contact information and name will not be attached to any of your responses. We ask that you not share any information, participants’ comments, or participants’ identities with others outside of your focus group.

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

• Risks: The discussion poses minimal, if any, risks to you. None of the questions are of a sensitive nature, so none of the questions should make you uneasy or uncomfortable. However, if any questions make you uncomfortable, you may choose not to provide an answer. As with any study, there is a chance that security of the information you share could be breached, but we will take steps to minimize this risk, as discussed below.

• Incentive: In appreciation of your time, you will receive an incentive of $75 for participating in today’s discussion.

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

• Observers: Individuals from the project team may be observing this discussion silently. They will not participate in the conversation.

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

• Contact Information: If you have any questions about this discussion, please contact Lindsay Gutekunst, Senior Vice President, at lgutekunst@krcresearch.com

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 discussion have been explained to me. I agree to participate in this discussion.

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Signature of Participant Date

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Signature of Person Obtaining Consent Date