Minnesota Refusal Questions

Study ID FORM APPROVED

OMB No. 0923-XXXX

10.8 reading level with burden statement; 5.7 without Expiration Date: MM/DD/YYYY

Attachment 5b. (MN 11)

Refusal Questions Form

Refusal Type (check one)

□ Hard Refusal

□ Consent Refusal

□ Blood Refusal

□ Questionnaire Refusal (Specimen-only Participant)

Suggested Script: I completely understand if being in the study doesn’t work for you. Instead, would you be willing to answer two short questions now? Your answers can help improve the study for others and give us some idea about whether people who are in the study eat different amounts of fish from the rest of the community. I can tell you what the questions are if you have just a few minutes.

If they agree, ask the following questions:

RQ 1.  About how many times per month do you usually eat fish (including canned tuna)?  Record answer below.

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

RQ 2. Would you be willing to tell me why you are unable to participate is the study? Prompt: if they only answer “Yes”, ask “is there any specific reason?” Record answer below.

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Date:___________________________ Staff Name:__________________________

Public reporting burden of this collection of information is estimated to average 2 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 (0923-XXXX).

Appendix 11 page 2