Informed Consent Form

Focus Group Discussion

Title of Study:

Researcher(s):

Institution:

Purpose of the Study

Procedures

Voluntary Participation and Withdrawal

Risks and Benefits

Confidentiality

Contact Information

If you have any questions about this study, please contact:

Consent

I have read and understood the information provided above. I have had the opportunity to ask questions and agree to participate in this Focus Group Discussion.

Name of Participant: Signature of Participant: Date: