Document ID: EPA-HQ-OPP-2011-0902-0005
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2011-12-07T05:00Z

Attachment C: Generic Release Form for Focus Group Participants
Interview Release Form  - Insert Date & Time
By signing below I agree to participate in consumer research interviews conducted by Shugoll Research at the date and time specified above in return for the specified payment listed below.  The research will be conducted at [insert location].   By signing this agreement, I hereby assign all rights, title and interest to any ideas, concepts or other intellectual property discussed or generated in the interview to [insert name of research company].  I understand that the interviews may be photographed or recorded and may be shared with [insert name of research company] employees, clients and corporate or business partners, and I give my consent to be photographed and recorded. I understand that I may be asked to try food or beverage products as part of the research.  I have no food allergies that limit my consumption of these foods and/or beverages and assume all risks associated with their consumption.
	

In return for my participation and agreement to the terms described above, I will receive $XX.

AGREED AND ACCEPTED BY:

_______________________________________		_____________________
(Signature)						(Date)

_______________________________________
(Print Name)

_______________________________________	______	_____________________
(Address)

______________________________	     _________	     ___________________________
(City)					     (State)                 (Zip code)