Att 5 - Example of Consent Form

Attachment 5: Example of EHS-Net Data Collection Informed Consent

Cooling Practices Study

Let me give you a little background on why I’m here and what we are going to be doing. I’m working with __________________ (state health department) on a research project designed to help us better understand cooling practices within restaurants. Your restaurant was picked at random to be in this project. Participation in this study is voluntary. You can choose to stop at any time. If you don’t want to be part of the study or if you change your mind later, nothing will happen to you. Whether you are part of the study or not will not affect your restaurant’s score on any health inspection.

Having said that, I need to let you know that if at any time during my visit I see something that is an imminent health hazard, such as no power, no water or sewage on the floor, I will need to stop the study and report the problem to your local health department.

I’m going to ask you some questions about this restaurant’s policies and practices. If any of the questions make you uncomfortable you can choose not to answer them. The information I collect today will be combined with information from other restaurants in various states and analyzed. Y

our name and your restaurant’s name will not be recorded on the data collection form, nor will they be included in any reports.

The information you provide will be valuable in helping us understand the difficult issues restaurants face, so we ask you to be as open and honest as possible.

After our interview, I’d like to observe cooling procedures within your establishment.

Do you have any questions?

If you have any questions at a later time, you can contact: (Local Contact Name). (If have card) My information is on this card.

Do you agree to let me interview you? (Check appropriate box)

If they say yes, continue with the interview.

If they say no, thank them and leave.