consent form

Reproductive Health and Family Planning: Consent Form

OMB#: 0990-0421

Date of Expiration: 10/16/2020

We are excited that you want to participate in a small group discussion as part of a study on reproductive health and family planning information and services. The purpose of these discussions is to learn more about your beliefs, attitudes and choices surrounding reproductive health and family planning. You have received services from [Title X clinic or Y Youth-Serving Organization], which is how we obtained your contact information, but these discussions are a separate study to collect information from young [women/men] in the [city/town] area. Whether or not you participate in the study has no impact on the services you receive through [Title X clinic or Y Youth-Serving Organization].

Your participation is voluntary and there are no negative consequences should you choose not to participate. You may choose not to participate in any aspect of the conversation if you do not feel comfortable. All of the information provided during these discussions will be kept confidential by the study team, and only members of our study team will have access to the information you share. Neither your name nor the names of others who participate will be reported. The notes we take about our discussions will only be seen by members of the research team. The notes will not be shared with or provided to the federal government or anyone else. No responses will be attributed to any individual person, rather they will be collected as a group and summarized. There is some risk that information shared during this discussion could be repeated outside of the group. Prior to the discussion, we will remind all participants not to disclose anything that they learn. The discussion will be about 90 minutes.

If you have any further questions that we may not be able to answer about this study or this discussion, please contact [name], the AIR Project Director at [phone] or via email at [email]. If you have any questions about your rights, please contact [name] by phone at [phone, a toll free number].

By signing this form, I agree to take part in this small group discussion being held in my community.

_________________________ __________________________ _______________

Your Signature Print Your Name Date

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0421. The time required to complete this information collection is estimated to average 90 minutes per response, including the time to review instructions and gather the data needed. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer