Consent Forms
*Note: Option 1 or Option 3 will be used. Option 2 will be used, if relevant.*
Form Approved
OMB No.: 0920-0735
Expiration Date: 3/31/2010
Option 1: Online Welcome Message
Welcome! Thank you for agreeing to help The Centers for Disease Control and Prevention (CDC) evaluate their [insert health topic] website/page/application. Your feedback is extremely important. We anticipate that it will take approximately [insert estimate] minutes to complete this questionnaire.
The first few questions will be about your purpose for using the CDC [insert health topic] website/page/application. Then we will ask you to perform some tasks on the website/page/application. We are not testing your abilities in any way; we are only testing the website/page/application to see how well it works. Please use the website/page/application in whatever manner is comfortable and normal for you.
Your responses to all questions will be kept in a secure manner. No personal identifiers will be recorded. All information is used for evaluation purposes only and does not involve sales of any kind. CDC does not plan to share the data with anyone outside CDC.
Click “Continue” to begin. To proceed through the survey, select your answer for each question and click “Next.”
Public reporting burden of this collection of information is estimated to average 5 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 (0920-0735)
Option 2: Audiotape and Videotape Consent Form
*Note: If used, this consent form will be present in conjunction with Option 1 or Option 3.*
Purpose: The purpose of this document is to obtain your consent to audiotape and videotape today’s usability testing session. We want record the session in order to analyze in depth at a later time the information collected today.
The tape will be used only internally within CDC and CDC does not plan to share the tape with anyone outside CDC. It will not be broadcast or used for any other purpose. The tape may be copied and used internally without further permission. No personal identifiers will be linked to the data and your signed consent form will be stored separately from the recording.
If you agree with this, please sign where indicated.
Print Name: _______________________________________
Signature: ________________________________________
Date: ____________________________________________
Option 3: Participation Consent Form
We are interested in your opinions!
We’ve revised The Centers for Disease Control and Prevention’s (CDC) [insert health topic] website/page/application and would like you to "try out" the new website. We want to know what works well for you and what doesn't, so that we can further improve the revised design.
During this session, we'll
1. Ask you about your background
2. Ask you to give us feedback on the new homepage
3. Ask you to perform a series of tasks to find information on the website
After you finish all of the tasks, we'll also ask you for your thoughts on the new design and suggestions for improvement. The whole exercise will take approximately one hour to complete.
During this session, we are keeping track of your interactions with the website, so that we can find ways to improve the website before it is launched.
The information that is captured will only be used to improve the website and for evaluation purposes. No personal identifiers will be linked to the data and your signed consent form will be stored separately from the recording.
To consent to the use and release of this information, please sign your name below.
Thank you for your time. Your opinion is very valuable to us!
Name _______________________
Date: _______________________
| File Type | application/msword |
| Author | PHPPO_User |
| Last Modified By | shari steinberg |
| File Modified | 2008-12-01 |
| File Created | 2008-12-01 |