Form Approved
OMB NO. ________
Exp. Date ________
Public reporting burden of this collection of information is estimated to average 3 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 may 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 NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXX)
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Flesch-Kincaid grade level: 6.8
“You are being asked to take part in a very brief research interview. This interview will take about 2 minutes to complete. We will not ask for your name. You can skip any questions you do not wish to answer.”
“The interview will help the Centers for Disease Control and Prevention and <insert local site information> figure out if this is a good place to sign up women for a future study about women’s health risks and behaviors. You will be asked your age, ethnic and racial group, and if you have been sexually active with at least one man in the past 12 months. You will also be asked if you are interested in taking part in the future women’s study. Your answer will only be used to give us an idea about who may be interested in joining this future study. It will not sign you up for the study. You can ask to get more information about this future study.”
“The risks and benefits of taking part in this interview are very minimal. Other people may see you talking to us and question your reason for doing so. Whatever you tell us will be shared only with our research team. You will not receive any money or gifts for taking part in this interview.”
“You can call XXX at XXXX if you have any questions about this interview.”
“Are you willing to take part in the brief interview today?”
| File Type | application/msword |
| File Title | APPENDIX NUMBER 3: Informed Consent Documents |
| Author | sxw2 |
| Last Modified By | sxw2 |
| File Modified | 2007-04-20 |
| File Created | 2007-04-20 |