Consent Check List

Program:

Focus Group Date:

• I do agree to being taped.
• I do not
• I do agree to notes being taken during the
• I do not focus group.
• I do want and
• I do not to use my ideas and words in a report or article.
• I do want my real name used.
• I do not

Assigned Pseudonym:

I understand what this study is about and agree to participate. I have been given a copy of this consent form.

Signature of participant: date:

Signature of interviewers: date:

date: