Special Consent

Attachment 5 – Special Consent

DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

Centers for Disease Control and Prevention

National Center for Health Statistics

3311 Toledo Road

Hyattsville, Maryland 20782

OMB #0920-0222; Expiration Date: 06/30/2015

Special Consent for Expanded Use of Video and Audio Recordings

Purpose

QDRL staff often presents what we learn from our projects at conferences or professional meetings. We would like your permission to show this recording to those who are interested in survey questions but who are not working directly on this project. If you agree, we may show the recording at conferences, for students, or for other people who write survey questions. In these cases, the recording is always under the control of QDRL staff.

Why do we want to show the recordings?

The recordings show how people react to survey questions. They show how questions can be hard to understand or hard to answer. They help people write better survey questions. It may also teach other researchers how to test survey questions.

Where might the recordings be shown?

We may show parts of the recording in a small meeting room, a classroom, or a large group at a professional meeting.

What information will be on the recording?

The whole recording could be shown. But it is more likely that a short piece will be shown about a problem with a question. No information about you will be added to the recording. However, your face and/or voice will appear on the recording.

What if I say yes now, but change my mind later?

If you change your mind, contact Karen Whitaker by phone at (301) 458-4569, or by mail at the Centers for Disease Control and Prevention’s National Center for Health Statistics, Room 6330, 3311 Toledo Rd., Hyattsville, MD 20782. You may change your mind at any time. When she receives your request, we will not allow special uses of your recording.

2. Questions

If you have any questions about this study, please call the office of the Ethics Review Board at the National Center for Health Statistics, toll-free at 1-800-223-8118. Please leave a brief message with your name and phone number. Say that you are calling about Protocol #2010-19-XX [Note: The amendment number will be inserted into the form once NCHS ERB approval has been received]. Your call will be returned as soon as possible.

If you have questions about Centers for Disease Control and Prevention’s National Center for Health Statistics privacy laws and practices, contact Eve Powell-Griner, Ph.D., Confidentiality Officer at 1-888-642-4159.

Either video recording or audio recording will be selected

When video recording is selected:

If You Agree, Please Read and Sign Below

 I allow the Centers for Disease Control and Prevention’s National Center for Health Statistics to show my video recording to people at conferences and meetings, to students, and to other people who write survey questions. I understand that my face and/or voice will appear on the recording. The recording will not be altered. The recording will be in the control of QDRL staff. If I change my mind at any time, I will contact Karen Whitaker, the NCHS Lab Manager.

• I do not allow the Centers for Disease Control and Prevention’s National Center for Health Statistics to use my video recording in this way.

When audio recording is selected:

If You Agree, Please Read and Sign Below

 I allow the Centers for Disease Control and Prevention’s National Center for Health Statistics to show my audio recording to people at conferences and meetings, to students, and to other people who write survey questions. I understand that my face and/or voice will appear on the recording. The recording will not be altered. The recording will be in the control of QDRL staff. If I change my mind at any time, I will contact Karen Whitaker, the NCHS Lab Manager.

• I do not allow the Centers for Disease Control and Prevention’s National Center for Health Statistics to use my audio recording in this way.

______________________________ __________________________ __________

Respondent Signature Print name Date

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