Store Owner/ Upper Management

Appendix D

Script to respondents for obtaining verbal consent to participate in survey

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

Script for Verbal Consent from Store Manager

The following script will be read to the store manager to obtain manager’s verbal consent to participate:

“We are requesting that you participate in a 20 minute interview as part of a research study being conducted by the National Institute for Occupational Safety and Health (NIOSH) which is part of CDC (Centers for Disease Control and Prevention)”.

The purpose of this study is to determine the impact of your city’s Convenience Store Safety Ordinance which became effective (enter effective date). We specifically want to determine if the ordinance has lead to an increase in the number of stores with robbery prevention security systems and a decrease in the number of robberies and assaults to convenience store employees. We also want to determine the benefits to convenience stores to comply with the city ordinance, that is has it led to a decrease in crimes, increase in quality of customers, a decrease in the amount of stress among workers, an increase in sales, and a positive return on investment which off sets the cost of the ordinance requirements.

We will ask you questions and record them on a questionnaire about the ordinance safety requirements and conditions in your store since passage of the ordinance. Your participation is voluntary and you have the right to refuse to answer any question. We will not record your name, and there will be no record of your name linked to any information you provide to us. We will not reimburse you for your time for this interview.

The benefits to you and the store will be to participate in an evaluation of the city ordinance. There is minimal risk to you to participate because your name will not be recorded. The information you provide on your store will not be provided to the city or the police department’s convenience store compliance program to ensure confidentiality to the store and to you. .We will prepare a report of our findings and we will send a copy of the report to your store as well as to the city.

If you have any questions regarding this research you can contact the NIOSH project officers (Dr. Harlan Amandus, 304-285-5753 or Dr. Cammie Chaumont Menendez, 304-285-6233). If you have any questions regarding your rights or if you are harmed or injured through negligence of a NIOSH employee or NIOSH contract employee you may be able to obtain compensation under Federal Law. If you want to file a claim against the Federal government your contact point is General Law Division of OGC, request the claims office, 202-233-0233; or NIOSH Human Subjects Review Board (Cheryl F. Estill, Chair NIOSH HSRB, 513-533-8591).

Public reporting burden of this collection of information is estimated to average 30 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).