Informed Consent To Participate In A Leading Indicators

Form Approved

OMB No. 0920-XXXX

Exp.Date__xx/xx/20xx__

Attachment G:

Informed Consent

INFORMED CONSENT TO PARTICIPATE IN A LEADING INDICATORS BENCHMARKING RESEARCH PROJECT

We would like to invite you to participate in a project being conducted by the University of Texas School of Public Health (UTSPH). The project is sponsored by the National Institute for Occupational Safety and Health (NIOSH) and the Ohio Bureau of Workers’ Compensation (OBWC).

The project’s purpose is to identify safety and health practices that reduce workers’ compensation claims and costs for Ohio wholesale and retail trade companies. Identifying safety and health practices associated with reduced claims and costs allows employers to better manage safety and health for improved outcomes. If you agree to participate:

• You will be asked to complete a 12 minute survey about your company’s safety and health practices and a little about your work background and general company information.

• Individual surveys will not be shared with OBWC.

• The survey data will be compared to past and future workers’ compensation data. Company data will be anonymously pooled with other companies to identify the safety and health practices most likely to reduce workers’ compensation losses.

• There is little anticipated risk to you from filling out the survey. Your name and your company’s name will not be disclosed in any UTSPH, NIOSH or OBWC reports. Data will be treated in a secure manner and will be protected to the extent provided by law.

• We will ask you to complete a follow-up survey in one year.

Your participation is voluntary and you may withdraw at any time without consequence to you or your company.

The new information gained is expected to improve our understanding of the safety and health practices that best prevent injuries and illnesses. There are no immediate direct benefits to you personally from participating.

If you have questions about this study, contact either Ben Amick or David Gimeno at the University of Texas School of Public Health (UTSPH). If you have questions about your rights as a member of this study, contact UT Compliance Hotline at 1-888-472-9868, www.uthouston.edu/compliance/reporting-issues/hotline.htm, or Mark Torrason at 513-533-8222, [email protected].

T hank you,

Public reporting burden for 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 the burden estimate to CDC/ASTDR Reports Clearance Officer, 1600 Clifton Road, NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).

Ben Amick, Ph.D. UTSPH 1200 Herman Pressler, Suite 1009 Houston, TX 77030 832-563-6859 [email protected]

David Gimeno, Ph.D. UTSPH 7411 John Smith Drive, Suite 1120 San Antonio, TX 78229 210-562-5500 [email protected]