My Mobility Product Testing Activities

OMB Control No. 0920-1050

Exp. Date 05/31/2022

Public reporting burden of this collection of information is estimated to average 2 minutes per respondent. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia, 30333; ATTN: PRA (0920-1050).

Attachment O. Consent Forms

Consent Form (English Groups)

Statement of Participation

Introduction and Purpose: The Centers for Disease Control and Prevention (CDC) is seeking feedback on a set of MyMobility resources. These resources contain information that can help people ages 60 or older protect their ability to get places they need to go as they age. You have been asked to take part in an online video group discussion. In the group, we will ask for your opinions and feedback on the MyMobility resources. RTI International, a non-profit company in North Carolina, is conducting this study on behalf of the CDC.

What will I have to do if I am in this study? If you choose to participate, you will take part in an online video group discussion with up to eight other people. The discussion session will last 90 minutes. During the discussion, you and the other individuals will be asked questions about MyMobility resources and your thoughts on how to improve them. We will provide you with copies of the materials you will be reviewing and ask that you review each resource prior to our call so you can be prepared to provide feedback on them. We will give you $75 for your time reviewing the resources and taking part in the group discussion. This gift card can be sent to you through the mail or digitally to the email address you provided.

What are the risks to being in this study? Participation poses minimal risks to you. If you feel uncomfortable expressing your opinions and ideas, you can choose not to answer any questions you do not want to answer.

What are the benefits to being in this study? You will not benefit directly from this study. However, the information you provide will help CDC improve the MyMobility resources.

What about my privacy and the confidentiality of the information I provide? All the information you share with us will be kept confidential. We will not include your name or other information in our notes or in any written reports that might identify you. We would like to record our discussion to make sure we accurately capture what you say in our report. You will not be identified by name in either the recordings or transcripts. Only members of our study team will have access to the recordings and the digital files. All files will be stored on secure password protected networks.

Do I have to participate in the focus group? Your participation in this group discussion is completely voluntary. You can decide whether to participate. If you agree to participate, you may stop at any time. If you choose to stop participating, you will still receive your $75 gift card. You may also choose not to answer any questions you do not want to answer. There are no right or wrong answers.

What if I have questions? Any questions you have about participating can be answered before we begin our discussion. If you have any questions before or after the group discussion, you may call the RTI International Project Leader Jon Poehlman at (919) 541-7068. If you have questions about your rights as a participant, please call the RTI Institutional Review Board Chair (toll-free) at 1 (866) 214-2043.

Participant’s Consent to Participate

I understand the nature and purpose of the MyMobility Study, as described above. I understand the activities involved in the focus group and my rights as a participant. I agree to participate in the group discussion.

Name of Participant (Print)

Signature of Participant Date

Consent Form (Spanish Groups)

Declaración de participación

Introducción y objetivo: Los Centros para el Control y la Prevención de Enfermedades (CDC, por sus siglas en inglés) están buscando opiniones sobre un conjunto de recursos de MyMobility. Estos recursos contienen información que puede ayudar a las personas de 60 años o más a proteger su capacidad de llegar a los lugares a los que necesitan ir a medida que envejecen. Se le ha pedido que participe en una discusión grupal mediante video por el Internet. En el grupo, le pediremos sus opiniones y comentarios sobre los recursos de MyMobility. RTI International, una empresa sin fines de lucro de Carolina del Norte, está realizando este estudio en nombre de los CDC.

¿Qué tendré que hacer si participo en este estudio? Si decide participar, intervendrá en una discusión grupal mediante video por el Internet con un máximo de otras ocho personas. La sesión de discusión durará 90 minutos. Durante la discusión, a usted y a las demás personas se les harán preguntas sobre los recursos de MyMobility y sus ideas sobre cómo mejorarlos. Le proporcionaremos copias de los materiales que revisará, y le pedimos que examine cada recurso antes de nuestra llamada para que pueda estar preparado para dar su opinión sobre ellos. Le daremos $75 dólares por el tiempo que dedique a revisar los recursos y a participar en la discusión grupal. Esta tarjeta de regalo se le puede enviar por correo o en formato digital a la dirección de correo electrónico que nos haya facilitado.

¿Cuáles son los riesgos de participar en este estudio? La participación supone un riesgo mínimo para usted. Si se siente incómodo expresando sus opiniones e ideas, puede optar por no responder a las preguntas que no quiera contestar.

¿Cuáles son las ventajas de participar en este estudio? No se beneficiará directamente de este estudio. Sin embargo, la información que proporcione ayudará al CDC a mejorar los recursos de MyMobility.

¿Qué pasa con mi privacidad y la confidencialidad de la información que proporciono? Toda la información que comparta con nosotros será confidencial. No incluiremos su nombre u otra información en nuestras notas o en cualquier informe escrito que pueda identificarle. Nos gustaría grabar nuestra conversación para asegurarnos que registramos con precisión lo que usted dice en nuestro informe. No se le identificará por su nombre ni en las grabaciones ni en las transcripciones. Solo los miembros de nuestro equipo de estudio tendrán acceso a las grabaciones y a los archivos digitales. Todos los archivos se almacenarán en redes seguras protegidas por contraseña.

¿Tengo que participar en la discusión grupal? Su participación en esta discusión grupal es completamente voluntaria. Puede decidir si participa o no. Si acepta participar, puede dejar de hacerlo en cualquier momento. Si decide dejar de participar, seguirá recibiendo su tarjeta de regalo de $75 dólares. También puede optar por no responder a las preguntas que no quiera contestar. No hay respuestas correctas o incorrectas.

¿Qué pasa si tengo alguna pregunta? Cualquier pregunta que tenga sobre la participación se podrá responder antes de comenzar nuestra discusión. Si tiene alguna pregunta antes o después de la discusión grupal, puede llamar al director del proyecto de RTI International, Jon Poehlman, al (919) 541-7068. Si tiene preguntas sobre sus derechos como participante, llame al presidente de la Junta de Revisión Institucional de RTI (llamada gratuita) al 1 (866) 214-2043.

Consentimiento del participante para participar

Entiendo la naturaleza y el propósito del estudio MyMobility, como se ha descrito anteriormente. Entiendo las actividades que implica la discusión grupal y mis derechos como participante. Estoy de acuerdo en participar en la discusión grupal.

Nombre del participante (en letra de molde)

Firma del participante Fecha

Consent Form (Tribal Groups)

Statement of Participation

Introduction and Purpose: The Centers for Disease Control and Prevention (CDC) is seeking feedback on a set of MyMobility resources. These resources contain information that can help people ages 55 or older protect their ability to get places they need to go as they age. You have been asked to take part in an online video group discussion. In the group, we will ask for your opinions and feedback on the MyMobility resources. RTI International, a non-profit company in North Carolina, is conducting this study on behalf of the CDC.

What will I have to do if I am in this study? If you choose to participate, you will take part in an online video group discussion with up to eight other people. The discussion session will last 90 minutes. During the discussion, you and the other individuals will be asked questions about MyMobility resources and your thoughts on how to improve them. We will provide you with copies of the materials you will be reviewing and ask that you review each resource prior to our call so you can be prepared to provide feedback on them. We will give you $75 for your time reviewing the resources and taking part in the group discussion. This gift card can be sent to you through the mail or digitally to the email address you provided.

What are the risks to being in this study? Participation poses minimal risks to you. If you feel uncomfortable expressing your opinions and ideas, you can choose not to answer any questions you do not want to answer.

What are the benefits to being in this study? You will not benefit directly from this study. However, the information you provide will help CDC improve the MyMobility resources.

What about my privacy and the confidentiality of the information I provide? All the information you share with us will be kept confidential. We will not include your name or other information in our notes or in any written reports that might identify you. We would like to record our discussion to make sure we accurately capture what you say in our report. You will not be identified by name in either the recordings or transcripts. Only members of our study team will have access to the recordings and the digital files. All files will be stored on secure password protected networks.

Do I have to participate in the focus group? Your participation in this group discussion is completely voluntary. You can decide whether to participate. If you agree to participate, you may stop at any time. If you choose to stop participating, you will still receive your $75 gift card. You may also choose not to answer any questions you do not want to answer. There are no right or wrong answers.

What if I have questions? Any questions you have about participating can be answered before we begin our discussion. If you have any questions before or after the group discussion, you may call the RTI International Project Leader Jon Poehlman at (919) 541-7068. If you have questions about your rights as a participant, please call the RTI Institutional Review Board Chair (toll-free) at 1 (866) 214-2043.

Participant’s Consent to Participate

I understand the nature and purpose of the MyMobility Study, as described above. I understand the activities involved in the focus group and my rights as a participant. I agree to participate in the group discussion.

Name of Participant (Print)

Signature of Participant Date