Needs Assessment: Informed Consent

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.

Contact:                        If you have any questions at all, feel free to contact Rachael Bazzett at cclibraryvista@outlook.com, rachael.bazzett@gmail.com or at the Coffman Cove Library at 907-329-2080. 

           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.

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Printed Name                                                                                        Date

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Signature