QDRL-OMB Attachment I

Attachment I

Form for special consent to send video and audio recordings to off-site researchers

DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

Centers for Disease Control and Prevention

National Center for Health Statistics

3311 Toledo Road

Hyattsville, Maryland 20782

OMB #0920-0222; Expiration Date: 02/28/2010

Special Consent to Send Video and Audio Recordings to Off-site Researchers

Purpose

We are asking for your permission to send the recording to [FILL AGENCY] so that the staff working on this project can view it at their location.

Only staff working on this project from [FILL AGENCY] will be allowed to borrow the recording. They must sign a contract with NCHS saying how they will protect your privacy and the recording until it is returned to NCHS.

What information will be on the recording?

The whole recording could be sent but, more likely, a short piece of the recording will be sent that shows a problem with a question. No information about you will be added to the recording. However, your face and/or voice will appear on the recording.

How will the recording be shipped?

The recording will be sent using Federal Express. It will be returned to NCHS by the same method.

What if I say yes now, but change my mind later?

If you change your mind, contact Karen Whitaker by phone at (301) 458-4569, or by mail at NCHS, Room 3101, 3311 Toledo Rd., Hyattsville, MD 20782. You may change your mind at any time. When she receives your request we will not allow the recording to be sent out.

Questions

If you have questions about NCHS privacy laws and practices, contact Mary Moien, Confidentiality Officer at (301) 458-4389.

If You Agree, Please Read and Sign Below

Permission to allow shipment of the recording to other locations:

 I allow NCHS to ship my interview to [FILL AGENCY] by Federal Express. I understand the recording will be returned to NCHS by Federal Express. If I change my mind at any time, I will contact Karen Whitaker, the NCHS Lab Manager.

• I do not allow NCHS to use my interview in this way.

______________________________ __________________________ __________

Participant Signature Print name Date