Consent to Participate (Paper)

Targeted Surveillance Consent to Participate in Research (Paper)

CONSENT TO PARTICIPATE IN RESEARCH – ATSS CORE SAMPLE (Paper)

RTI International is working with the Centers for Disease Control and Prevention on a study in your area.

• The research study asks about what you eat, your exercise habits, health care, and physical and mental health. Section 301 of the Public Health Service Act permits the Centers for Disease Control and Prevention to collect this information.  

• You were selected at random from other people in your area to be part of the study. You can choose whether to be in the study or not. If you decide to take part in the study and change your mind later, you will not be contacted again or asked for any more information.

• About 12,000 people will take this survey this year.

• There is no direct benefit to you if you take part. But your answers will help us find out how to improve the health of your community and others across the country.

• The survey takes about 28 minutes. There is very low risk to the survey. We just ask you to answer questions in a paper booklet. You can skip any questions and stop at any time. We will not share your answers with anyone not working on the study. No one will be able to identify you or your answers by looking at the results of the study.

• To take part, please record your answers in the booklet using a pen with blue or black ink.

• After we receive your completed survey, we will send you your choice of either a $20 check or a $20 gift card to Walmart. Your contact information will kept separate from your answers. We will also keep your contact information private. Sometimes people call us but do not have a case ID on hand. In such cases, specially trained staff members will search our records system to find the case ID associated with the callers’ household. These staff members will be trained to carefully avoid sharing your contact information with anyone. Your contact information will be permanently deleted after you have completed all parts of the study and have received your check or gift card.

If you have any questions about the survey, please contact Brenna Muldavin, our survey manager. You can reach her by calling this toll-free number (800-844-8959). Or email her at {study-specific email address}.

If you have questions about your rights as a member of this study, please contact RTI’s Office of Research Protection at this toll-free number: 1-866-214-2043.

If you agree to be part of this study, please complete this survey booklet.

Consent Version: 06-06-2012 page 1 of 1

RTI IRB ID: 13033

RTI IRB Approval Date: 07-18-2012