Worker screener and consent

Form Approved

OMB No. 0920-0792

Exp. Date 10/31/2011

Attachment 10- EHS-Net KMC Study Worker Recruiting Screener and Informed Consent

Let me give you a little background on why I’m here. I’m working with __________________ (health department) on a research project. Your restaurant was picked at random to be in this project, and your manager said that it would be okay for you to talk to me for a few minutes. However, your participation is voluntary—you don’t have to talk to me if you don’t want to- I won’t tell your manager. If you do talk with me, I won’t tell your manager anything that you say.

Would you be willing to talk to me for about 10 minutes about your work behavior and this restaurant’s policies and practices?

No  Okay, thanks for your time. (End interview)

Yes  Great, thanks.

I’m going to ask you some questions, and if any of the questions make you uncomfortable you can choose not to answer them. The information we collect today will be combined with information from other restaurants in various states. Your name and your restaurant’s name will not be linked in any way to the information we collect, nor will they be included in any reports.

The information you provide will be valuable in helping us understand the food safety knowledge level and attitudes of food workers, we ask you to be as open and honest as possible.

Do you have any questions?

Public reporting burden for 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 Information Collection Review Office, MS D-74; 1600 Clifton Road NE, Atlanta, Ga. 30333; ATTN: PRA (0920-0792)

If you have any questions at a later time, you can contact: (Local Contact Name). (If have card) My information is on this card.