Attachment F_IRB-Consent-Form

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Attachment F

IRB Consent Form

Consent to Participate in Research

Title of Research: Childhood Experiences Study

Introduction

You are being asked to participate in a research study. Before you decide if you want to take part, you need to read this form to understand what the study is about and what you will be asked to do. This form tells you who can be in the study and the risks and benefits of the study. It also explains how we will protect your information and who you can call if you have questions. Please call the phone numbers listed on the following pages if you would like anything you don’t understand to be explained. You may do this before making a decision about whether or not to participate in this research study.

Purpose

This study is being paid for by the Centers for Disease Control and Prevention (CDC). CDC is a government agency that promotes public health in the United States. The study is being run by RTI International. RTI is a research organization in North Carolina. RTI has contracted with Knowledge Networks (KN) to collect survey data. The goal of the study is to learn about how childhood experiences impact life as a child and as an adult. You are one of 1,850 adults invited to be part of this study.

Procedures

If you agree to participate, you will be asked to complete a survey. The survey will ask about your past and current aspects of your mental and physical health and relationships. It also asks about anger, aggression, and risky behaviors including substance abuse. The survey will also ask about your experiences as a child. You will also be asked to compare these different health conditions.

Study Duration

The survey will take about 25 minutes.

Possible Risks or Discomforts

Risks from the Interview Some of the questions we ask may make you uncomfortable. You can refuse to answer any question. You may take a break at any time during the survey. Knowledge Networks will protect your responses under its Privacy Policy. RTI and CDC will receive only your survey responses, no personal identifiers. RTI will make every effort to protect your responses, but this cannot be guaranteed.

Some parts of the survey discuss health conditions. Other parts discuss child experiences and behaviors. Some of these experiences may have been distressing. You may feel discomfort after thinking about some of these topics.

Benefits

Your Benefits There are no direct benefits to you from being in this study.

Benefits for Other People This study will help CDC to understand how childhood experiences affect quality of life. The data will be used to inform public health programs. This in turn may help to improve the quality of life for all children and adults.

Payment for Participation

You will receive KN points for your time to participate in the study.

Confidentiality

Many steps have been taken to protect your information. KN will report only your responses to RTI, not your name or contact information. If the results of this study are shared at scientific meetings or in journals, no information will be included that could identify you.

Your Rights

Your decision to take part in this research study is completely voluntary. You can refuse any part of the study and can stop at any time. You can refuse to answer any question.

Your Questions

If you have any questions about the study, you may call the study director, Dr. Derek Brown. His phone is 1-800-334-8571, x23514. If you have any questions about your rights as a study participant, you may call RTI’s Office of Research Protection at 1-866-214-2043.

YOU MAY PRINT A COPY OF THIS CONSENT FORM TO KEEP.

By clicking the “yes” box below, your electronic signature indicates that you have read the information provided above, have received answers to your questions, and have freely decided to participate in this research. By agreeing to participate in this research, you are not giving up any of your legal rights. If you do not agree, please check the “no” box.

• Yes, I agree to participate. [continue with next section]

• No, I do not agree to participate. [go on to next question]