3 survey

Appendix F – Consent Form to Receive Text Messages

AGREEMENT TO RECEIVE TEXT MESSAGES

FOR RESEARCH

As part of a research study, I agree that (Westat) may send me up to three surveys via text messaging on a phone number that I designate. The surveys will range from 5 to 12 text messages each.

I understand that I can change my mind at any time and decide not to receive any text messages from (Westat).

I also understand that if I do change my mind, in order for (Westat) to remove me from the text contacting list, I must call 1-800-XXX-XXXX and ask that (Westat) discontinue sending me text messages.

Signature Date

Printed Name

Public reporting burden for this collection of information is estimated to average 0.03 hours (2 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0590). Do not return the completed form to this address.