Researcher
Name: ______________________________

Address: ____________________________

Thank you for agreeing to participate in this Rapid Assessment Process (RAP). This form outlines the purposes of the study and provides a description of your involvement and rights.

The purpose of this activity is to get your opinions, insights, and suggestions about:
______________________________________________________________

______________________________________________________________

You are encouraged to ask questions at any time about the study and the methods we are using. Your suggestions and concerns are important to us.

We will use the information from this study to write a report. The report will be a public document.

Unless you are asked to sign a separate statement at the bottom of this form, your real name will not be used at any point in the written report. Instead, you and any other person and place you name will be given fictitious names (pseudonyms) that will be used in all verbal and written records and reports.

Audiotapes of interviews will be used only for this study and will not be played for any reasons other than to do this study.

Your participation in this study is voluntary. You have the right to withdraw at any point of the study, for any reason. If you withdraw, information collected from you and records and reports based on information you have provided will not be used.

Do you agree with the terms of this agreement?_________ (please write in YES or NO)

Your name (printed)_________________________

Your signature ____________________________ The date_______________
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Special Consent to Use My Real Name

There may be special circumstances in which the use of your real name is desirable, such as the need to add credibility to statements or indicate support for proposed actions suggested by the community. If there is a possibility that your real name will be used, you will be asked to sign below. If your real name is used, you will be given the opportunity of reviewing the draft report and suggesting changes before it is finalized.

Do you grant permission for the use of your real name? ________(please write in YES or NO)

Your signature ___________________________ The date_______________

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James Beebe
Last update
17 Aug 03