Appendix 6_Participant Consentv4

Survey of Residential Fire Injury Incidents

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Form Approved: xx-xx-xxxx
OMB No: 0920-xxxx
Expiration Date: xx-xx-xxxx

Consent Form
Hello, I’m ______________ from Battelle, in _________________. May I speak with ___________?
(She/He) was previously contacted by us concerning a fire incident in your home on __________.
The National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention
(CDC) is conducting this study to obtain information that will help inform the development of programs
aimed at reducing residential fire injuries and deaths in the United States. The information about your
experience in a home fire may assist other individuals who are confronted with a similar situation.
Participation in this survey is voluntary. Under the terms of the Privacy Act of 1974, we are required to
treat your answers as completely confidential. The information you give us will be greatly appreciated.
Your responses will provide vital information on the actions of people in household fires. Let’s take a few
minutes to review the consent form. REVIEW CONSENT FORM WITH PARTICIPANT.
During this interview, you may ask questions or stop the interview at any time. The interview will start out
by having you tell me, in your own words, what happened during the fire incident. After you are done, we
will fill out a form together cataloguing what you did during the fire incident, step by step, to make sure
everything is covered. Then you will be asked a series of questions that will help us to better understand
factors related to residential fires.

Why is this study being done?
You are being asked to participate in a research study about what people do when there is a fire
in their home. This study is being done by Battelle Centers for Public Health Research and
Evaluation. It is funded by the Centers for Disease Control and Prevention (CDC). Authority for
CDC to collect this data is granted by Section 301 of the Public Health Services Act (42 U.S.C.
241). This act gives federal health agencies, such as CDC, broad authority to do many public
health activities, including this type of research. The University of Maryland is also a research
partner. Dr. Jim Milke leads the University of Maryland team. We are asking you to be in this
study because you recently experienced a fire in your home. Your contact information was
shared with us by your local fire department. This study will help us learn about behaviors that
may prevent individuals from becoming injured in a fire.

Public Reporting burden of this collection of information is estimated at 60 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is
not required to respond to a collection of information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74,
Atlanta, GA 30333; Attn: PRA (0920-XXXX).

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What does this study involve?
As part of this study, we will ask you to participate in a face to face interview. First, you will be
asked to describe what you did when you had the fire in your home. Second, you will be asked
several questions related to the fire. Examples include the type of house you live in and prior fire
safety training. We will ask you some basic personal information such as your age and race. We
will also ask questions about your health. Your answers can help us find the best ways to teach
people how to prevent injuries during fires. A computer will audio record this interview. The
interview will last approximately an hour. You will be given $25.00 upon completion of the
interview to cover your time.

Will this information be kept private?
Battelle staff will conduct the interviews. They will record your responses on a computer.
Battelle will keep all the information you provide in a secure computer system or locked cabinet.
This includes the audio recordings. Only study staff will have access to this information. We will
protect your privacy to the extent allowable by the law. All facts from this study that can
describe you will be kept private. All identifying information will be destroyed within 6 months
of the final report. Recordings will be destroyed within one year of the final report. Data without
your private information may be stored for future use.

We are applying for a Certificate of Confidentiality. This is additional protection to keep your
answers private. We will not give anything you tell us out to anyone. We cannot share your
information even if a court tells us to do so. We can only share your information if you say it’s
okay. By law, we do have to report to the state suspected cases of child abuse. We also have to
report if you tell us you are planning to cause serious harm to yourself or others.

Are there risks to doing the interview?
There are some potential risks in doing the interview. Some people may feel uncomfortable or
upset when talking about their fire experience. Please tell us if you feel upset at any point and
would like to talk to a professional. We will give you a list of people to call.

You may refuse to answer any questions during the interview. You may stop at any point if you
feel upset and do not feel like you can continue. These feelings may go away after the interview.

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However, if they don’t you should call one of the professionals listed on the referral sheet that
we will give you.

You will get no direct benefits for doing the interview. However, you will provide information
that may help people like yourself. You may also potentially help save the lives of people who
have a fire in their home.

How can I get out of this study?
Your participation in this study is voluntary. You are free to join the study or decide not to join.
If you do not join, you will not lose any fire department services that you expect to get apart
from this study. You may also leave the study at any time for any reason. Should you choose to
withdraw from the study, information you have already provided will not be used in the study
and will be deleted.

Who do I contact about questions?
If you have any questions or concerns about this study or feel you have been harmed, please call
one of the following:
1) Ms. Kathy Tiefenwerth from Battelle. Her number is 410-372-2755.
2) Dr. Jim Milke from the University of Maryland. His number is 301-405-3995.
3) Dr. Shane Diekman from the CDC. His number is 770-488-4901.

If you have questions about your rights as a subject in this research study, please call one of the
following:
1) The Institutional Review Board of Battelle. Dr. Margaret Pennybacker’s phone number is
1-877-810-9530.
2) The Institutional Review Board of the University of Maryland. Their email is
[email protected]. Their telephone number is 301-405-0678.
3) Office of Scientific and Regulatory Services for CDC. Their number is
1-800-584-8814. Please leave a message including your name and phone number. Refer
to protocol #4636. Someone will call you back as soon as possible.

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My consent
I have received a signed copy of the consent form. A copy will also be kept in the study file. If
there is any part of this form that is unclear to me, I can ask questions about it. I will not sign until
I get answers to all of my questions. By signing the form, it shows that I agree to join this study.

______________________________
Date

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_____________________________________________
Signature of Study Participant