Consent Form

Form Approved

OMB No. 0990-0281

Exp. Date XX/XX/XX12

Healthy People 2020 Consortium Assessment Survey Consent Form

Your Permission for the Survey

About This Project

The Healthy People Consortium (Consortium) has been the public and private sector voice for Healthy People for the past two decades. To provide Consortium members with the information and resources needed for effective networking and communication, ODPHP would like to survey the members.

As a consortium member, we would like to hear from you. The survey will take approximately 10 minutes to complete. Information provided will be used to:

• To learn more about the interests and needs of the Healthy People 2020 Consortium members

• To gather information to develop a Consortium Networking and Communication Plan that will serve and benefit you

• To allow tailoring of Healthy People information—so you receive the information you are interested in; information you can readily use with your networks and colleagues.

An e-mail invitation to complete the survey will be sent to you. The link will contain a unique ID so we can send follow up e-mail reminders only to members that have not completed the survey. Your contact information will not be linked to your responses. Survey monkey will be used to administer the survey. There will be no risk to you. You do not have to answer any question you don’t want to answer. You may stop participating in the survey at any time.

This project is sponsored by the US Department of Health and Human Services. The American Institutes for Research is helping with the survey development, instructions, and analysis. If you have any questions about this project, please call Eloisa Montes at (301) 592-2239.

If you have questions about your rights or think you have been harmed, please call someone from the Human Research Helpline at 1-800-584-8814. Leave a message with your name and phone number, and someone will call you back as soon as possible.

Thank you for your time.

Participant Consent

By signing below I show that I read the “About this Project” statement and know my rights as a participant. I agree to participate in Healthy People 2020 Consortium Assessment Survey. I understand that neither my name nor identity will be used in any report or other products that may come out of this project.

If you decide to sign this form, it means that you agree to be part of the study and to participate in this survey. Do not sign until you have answers to your questions.

If you choose to take part in this study, please sign, print your name, and write today’s date below:

Sign Here: ____________________________________________

Print Name:___________________________________________

Today’s Date: _______________

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