Attachment A5_Focus Group Informed Consent Form

Attachment 5

Program Participant Focus Group Informed Consent

NORC at the University of Chicago

Chicago, Illinois

NORC Protocol/PD # 6769

CONSENT TO PARTICIPATE IN AN EVALUATION STUDY

TITLE OF STUDY: Evaluation of the Tribal Health Profession Opportunity Grant

Project Director: Michael Meit, MA, MPH

Phone Number: (301) 634-9324

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The Administration for Children and Families (ACF), which is part of the U.S. Department of Health and Human Services, would like to learn how the programs they funded to improve health professions opportunities in Tribal communities are working. You will be one of approximately [xx] people across the country participating in discussion groups for this study.

Evaluation Team:

ACF has contracted with NORC at the University of Chicago, a non-profit evaluation organization, to conduct this study. This study is under the direction of Michael Meit, MA, MPH. Other professional persons who work for NORC may assist or act for him.

Procedures:

During the focus group, you will be part of a group of about [x] people. Moderators from NORC will lead the group in a discussion. The session may be tape-recorded to assist us in taking notes and summarizing the discussion, and 1 to 3 other individuals from NORC, may also listen to the discussion.

Duration:

We expect that your participation will last approximately 90 minutes, just the length of the discussion group. You can stop participating at any time, and there are no consequences for you if you should stop. However, if you decide to stop, we encourage you to talk to us first.

Risks and Discomforts:

We may be asking you questions about your reasons for participating in the [GRANTEE] program, and how the program has affected you. We understand that this information is personal. You do not have to reveal any personal information unless you choose to do so.

Benefits:

We will provide ACF with a summary of the discussion so they can understand your experiences with the [GRANTEE] program. The summary will only include aggregate information and will not identify any participant. This information will help to determine the best approach to designing programs to improve health professions opportunities in Tribal communities and ultimately improve health in Tribal communities. However, we cannot guarantee that you will personally experience benefits from participating in this study.

Privacy:

You will not be identified in any report or publication of this study or its results. We will keep information about you private, and protect it from unauthorized disclosure, tampering, or damage. Any potentially identifying information, including audio tapes from the discussion group, will be kept in a secure location during the period of the study. This information will be used only for the purposes of the study and will be destroyed no later than three years after the project is over. NORC does not intend to provide Personally Identifiable Information to ACF and will take measures to protect this information from inadvertent disclosure. Your name and any material that could identify you will remain private.

Payments to Participants:

Your compensation for this focus group will be a $50 non-cash gift card or voucher.

Right to refuse or to withdraw from the study:

Your participation is voluntary. You may refuse to participate, or may discontinue your participation at any time without penalty and without losing benefits to which you would otherwise be entitled.

Offer to Answer Questions:

You have the opportunity to ask, and to have answered, all your questions about this evaluation. If you have other questions, you may call Project Director Michael Meit at (202) 634-9324.

Institutional Review Board Approval:

If you have questions about your rights as a study participant, you may call Kathleen Parks, the NORC IRB Administrator, toll free, at 866-309-0542.

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Subject’s Agreement:

I have read the information provided above. I voluntarily agree to participate in this study. After it is signed I understand I will receive a copy of this consent form.

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Signature of Evaluation Subject Date

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Signature of Person Obtaining Consent Date