Assessing the Safety Culture of Underground Coal Mining Survey

Attachment C1 Form Approved

OMB # ________

Expires ________

Phase B, Survey Oral Consent Script

First off, we want to thank you very much for your time. Today we are conducting a research study and we would like to have you all fill out a questionnaire. This study is being done by The National Institute for Occupational Safety and Health (NIOSH). NIOSH is part of the Centers for Disease Control (CDC), a government agency in the Department of Health and Human Services. We collect this information in order to learn about various kinds of work hazards that may influence the health of the American worker. We are looking at safety in coal mining and trying to understand what it is like and make recommendations for how it can be improved. The first part of this study will involve filling out a questionnaire. This should take about 20 minutes. Please do not write your name on this questionnaire as it is completely anonymous and you will not be linked to your responses. Information collected from you will be kept confidential and no individual data will be reported from this study. Results will only be reported by groups representing at least 8 or more individual responses.

The questions on this survey pose minimal risk to you, if you participate. You may choose not to answer any question. This study involves minimal risk. Questions are not of a sensitive nature and you may chose not to answer any or all of them. If you have any comment about the tests/procedures, you should contact Katherine A. Margolis, Principal Investigator, 412.386.4627. There are also no individual benefits to participation. Your participation is entirely voluntary and you have the right to discontinue your participation without penalty. If you stay and complete the survey this is an indication that you consent to participating in this portion of the study.

Public reporting burden of this collection of information is estimated to average 20 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 E-11, Atlanta, Georgia 30333; ATTN: PRA (0920-09BH).