Focus Group Consent Form 11-4-2022

Can you please submit this Corp Council for review? This involves minors so we are requesting a review. The contract amount is $20 in a gift card.

Description (please pass along to Corp Council): 

Sauk County Health Dept will be conducting focus groups with teen participants between ages 14-18. This activity will be conducted to fulfill grant requirements. Attached is the consent form we are requiring all participants and parent/guardians to complete prior to participating in a group. We will ask teens to register online here: https://www.cognitoforms.com/SaukCountyHealthDepartment/RegisterForFocusGroup AND submit a signed consent form through Cognito Forms.

Any questions can be directed to me or Sara Jesse.

Focus Group Consent Form

Please read this form carefully and ask any questions you may have before agreeing to take part in a focus group.

What the focus group is about:

The purpose of this focus group is to learn why some youth and young adults in your community vape nicotine products and or use alcohol. This focus group is being conducted by Sauk County Partnership for Prevention/Sauk County Health Department.

Participant Eligibility:

Consent forms must be signed by the participant as well as their parent/ guardian.

Participants must be able to provide transportation to and from the focus group location.

Participants must participate in the entire focus group to qualify for the $15 gift card.

What we will ask you to do:

Participants will be asked to take part in a one-hour conversation about substance use in your community. We will not directly ask you if you vape or use alcohol.

Risks:

If initiated by focus group participants, other topics of discussion may include different types of drug use, as well as illegal activities, such as underage vaping and illegal sales to minors.

Sauk County Health Department staff and volunteers promise to retain the anonymity of focus group participants in all communications verbal and written, internal and external, but cannot prevent other focus group participants from violating expectations of confidentiality. Sauk County Health Department cannot guarantee that participants will not be familiar with other participants in the group.

Benefits:

Participants will have the opportunity to inform Sauk County Partnership for Prevention’s efforts to reduce youth substance use across Sauk County. Participants will also receive a $20 gift card for their time.

All answers will be confidential and group records will be kept private. Public reports based on information from this focus group will not include information that will make it possible to identify you. Research records will be kept in a locked file accessible only to Sauk County Health Department staff.

Voluntary Participation: Taking part in a focus group is completely voluntary. You are encouraged to answer “pass” when asked any question you do not want to answer during the focus group. If you turn in a completed consent form, you are free to withdraw at any time.

For questions: If you have questions at any time, you may contact Kate Stough, Health Educator, at 608-477-3609 or kate.stough@saukcountywi.gov .

Participant Statement of Consent: I have read the information offered on the first page of this document and have received answers to any questions I have asked. I consent to take part in this focus group and to be contacted via text and email with reminders about the focus group.

Your Signature                                                                        Date                                                                                               

Your Name (printed)                                                                                                                                         

Parent/Guardian Statement of Consent: I have read the information offered on the first page of this document and have received answers to any questions I have asked. I consent for the individual named above to take part in this focus group and to be contacted via email with reminders about the focus group.

Parent/Guardian Signature                                                                       Date                                                                                                                   

Parent/Guardian Name (printed)