Appendix E_Consent Form

Appendix E

Consent Form

CONSENT TO PARTICIPATE IN A RESEARCH STUDY

National Employee Well-Being Survey

NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH (NIOSH)

CENTERS FOR DISEASE CONTROL AND PREVENTION

U.S. PUBLIC HEALTH SERVICE

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

You have been asked to participate in a NIOSH research study. NIOSH has contracted with Research Triangle Institute (RTI) to collect data for this study. RTI is a not-for-profit research organization affiliated with Duke University, the University of North Carolina at Chapel Hill, and North Carolina State University.

We explain here the nature of your participation, inform you of your rights, and specify how NIOSH will handle your records. Employee records include any questionnaire data that is collected and records such as days absent/year, days of sick leave/year, worker=s compensation claims and productivity All information that is collected will remain strictly confidential. You may withdraw from the survey at any time without penalty and you may choose to not answer any question you are asked.

After reviewing this document, please provide the requested information, sign it, and return it to:

Dr. Naomi Swanson

National Institute For Occupational Safety & Health

Robert A. Taft Laboratories

4676 Columbia Parkway, MS C-24

Cincinnati, Oh 45226-9987

You will need to put one $.37 stamps on the envelope. If provided,
use the self-addressed, postage paid envelope found in your packet.

If you would like to request a postage-paid envelope please call
1-800 334-8571 ext. 3525.

I. PROJECT DESCRIPTION

1. Title: National Employee Well-Being Survey

2. NIOSH Contact Person: Naomi Swanson, Ph.D., National Institute for Occupational Safety and Health (NIOSH), Taft Laboratories MSC-24, 4676 Columbia Parkway, Cincinnati, Ohio 45226

3. Purpose and Benefits: The purpose of this study is to determine the relationship between various working conditions, company programs, and employee health.

There are no immediate, direct benefits to you for participating in this study although things that we learn may help us to improve the general quality of working conditions in the future.

After the study is completed and the results are analyzed, a summary of the evaluation will be provided by NIOSH to study participants.

II. CONDITIONS OF THE STUDY

1. This study will take place during the time period beginning May 2004 and continuing for the next five years. As a participant in the study, you will be asked to participate in a telephone survey on a yearly basis. Part of the survey will be conducted by a telephone interviewer and part will be conducted in private using a touch-tone key pad. The survey will contain questions about your working conditions, company programs, and your health and well-being. The survey will be conducted at the beginning of the study, and then once a year for the following two years, for a total of three interviews. Each interview will last about 45 minutes.

2. Your participation in the surveys, or any other data collection procedures, is voluntary; thus, you may withdraw your consent for those activities at any time. You will be reimbursed $25 for each survey that you complete. You may choose not to answer any question in the survey, but if you do not listen to every question in the survey, you will not be reimbursed the $25. All data will remain strictly confidential.

3. Your permission is requested for your employer to provide NIOSH with additional information such as days absent/year, days of sick leave/year, worker’s compensation claims and productivity. This information will be linked to the interview data, but such linkages will remain strictly confidential, and all results will be reported on a group basis only.

4. Participation in this study is not associated with any risks or discomforts beyond what could occur to a regular employee of your company who is not participating in the study. The sensitive nature of some of the questions may cause distress, but you may choose not to answer any of the questions for that or any other reason.

5. If during the interview you state that you are having thoughts of harming yourself and/or others, we will contact either a national suicide hotline or emergency response personnel.

6. If you have any questions about this research, you should contact Naomi Swanson, Ph.D., NIOSH Principal Investigator, at (513) 533-8165. If you have questions about your rights or treatment as a participant of this study, contact Michael J. Colligan, Ph.D., Chair, NIOSH Human Subjects Review Board, at (513) 533-8222. Or you may call Wendy Visscher at RTI’s Office of Research Protection and Ethics at 1-866-214-2043.

7. The overall study results will be provided to your employer. Individual information, such as your name, will not be revealed in the report and the results will be grouped across all companies participating in the study.

III. USE OF INFORMATION

To further protect the personal information you will share with us for this study, the National Institute for Occupational Safety and Health (NIOSH) of the Centers for Disease Control and Prevention (CDC), an agency of the Department of Health and Human Services (NIOSH), has been authorized to give an Assurance of Confidentiality under Section 308(d) of the Public Health Service Act (42 USC 242 (d)). This Assurance of Confidentiality goes to great lengths in assuring the privacy and security of your personal information. This means that any information that CDC/NIOSH has that identifies you will be used only for this study and cannot be disclosed to anyone unless you give your consent. NIOSH is authorized to collect this information, including your social security number (if applicable), under provisions of the Public Health Service Act, Section 306 (42 USC 242k); the Occupational Safety and Health Act, Section 29 (29 U.S.C. 669); and the Federal Mine Safety and Health Act of 1977, Section 501 (30 U.S.C. 95). The information you supply is voluntary and there is no penalty for not providing it. The data will be used to evaluate worker well-being. Data will become part of the CDC Privacy Act System (09-20-0147), “Occupational Health and Epidemiological Studies,” and may be disclosed to private contractors assisting NIOSH.

IV. SIGNATURE

I have read this consent form and I agree to participate in this study.

PARTICIPANT_________________________________________________ Age____________

(Print your name neatly here)

_______________________________________________________ Date___________________

(Signature)