Participant Consent

D3. Participant Consent Form

CDC Pilot Study of Community-Based Surveillance of Supports for Healthy Eating/Active Living

Consent to Participate

[NOTE: A COPY OF THIS PARTICIPANT NOTIFICATION WILL BE PROVIDED TO RESPONDENTS IN AN ADVANCE MAILING. THIS TEXT WILL ALSO BE DISPLAYED ON SCREEN AFTER PARTICIPANTS LOG INTO THE WEB-BASED QUESTIONNAIRE, BEFORE THE FIRST SET OF QUESTIONS IS DISPLAYED.]

You have been invited to take part in the Pilot Study of Community-Based Surveillance of Supports for Healthy Eating/Active Living (CBS HE/AL Surveillance Pilot Study), a research project sponsored by the Centers for Disease Control and Prevention (CDC). The pilot study seeks to gather information on the policies enacted by local governments to encourage, support, and facilitate community-level improvements in healthy eating and active living for residents as a part of a comprehensive national surveillance system. This pilot study is being conducted in 2 states and includes over 400 local municipalities. The pilot study will ask about the existence of certain policies and standards that promote more healthful eating and physical activity for residents.

You were identified as the person best able to address questions about the policies enacted by your local government. Your participation in this study will involve responding to a web-based questionnaire which will take approximately 60 minutes to complete.

Your participation is voluntary and you may stop participating at any time. You have the right to refuse to answer any question. Your participation will be treated in a secure manner and will not be disclosed required by law. The information you give us will be combined with the responses of participants in other staff in other communities in a summary report. The CDC will provide your local government with a brief summary report that compares the findings from your community with those of similar communities within your State. There are no risks or benefits to you for participating.

If you have any questions about the study, please call Dr. Deborah Galuska of the CDC at 770-488-6017 or Dr. Erika Gordon of ICF International at 1-800-XXX-XXXX. A review board at ICF International and CDC has determined this study to be exempt from the human subjects review process. If you have any questions about your rights as a study participant, you can call XXXXXX of the CDC at 1-800- XXX-XXXX.

You may access the questionnaire at http://www.CBSSURVEYWEBSITE HERE.com to participate. Please refer to the materials enclosed with this form to obtain further information on how to complete this questionnaire and determine what your token ID is to access the questionnaire.

Thank you.