Informed
Consent Form
Interview/Focus
Group Participation
Community
Needs Assessment of Coffman Cove
Interviewer: Rachael Bazzett, MSW.
AmeriCorps VISTA Volunteer
Funding
Agency: AmeriCorps VISTA
Purpose of Interview: The purpose of this interview is to learn
about the community of Coffman Cove. The information gained through these
interviews will be used to inform the development of programs that will be
offered through the Coffman Cove Community Library. This interview has a focus
on the economic circumstances of individuals and the community as a whole,
including impacts of employment/unemployment, prevalence of subsistence means
of living, availability of job opportunities, and availability of learning or
skill-training opportunities for residents of Coffman Cove.
Risks/Benefits: There are no known risks for
participating in an interview or focus group for the community needs
assessment. The interviews will be recorded, transcribed, and then deleted.
Transcripts from the interviews will exist in a digital file that is accessible
to only the interviewer. Information collected from this interview will be used
in a written community needs assessment that will be made available to the
public. Common themes from interviews will be used in this report as well as
direct quotes that are free from identifying features. Other demographic
information that is collected will be reported in aggregate form.
Your Rights: It is your choice to
participate in this interview, and you may change your mind about participation
at any time. You do not need to answer every question if you do not feel
comfortable doing so. Feel free to give the interviewer feedback.
I understand
what I am being asked to do.
I agree to
participate in an interview.
I agree to
use of direct quotes (free from identifying features) in the needs assessment
report.
. .
Printed Name Date
.
Signature