Consent to Participate (Phone)

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

IF RESPONDENT INTERRUPTS, YOU MAY SAY: Before we can continue, I need to read this entire statement word for word.

RTI International, a nonprofit research group, is doing a study on health issues in your area for the Centers for Disease Control and Prevention. The 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 this study. About 12,000 people will take this survey this year.

In order to evaluate my performance, my supervisor may record and listen as I ask you questions.

You can choose to take part 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. There are no direct benefits to you for being in this study. But your answers to the survey will help us to understand what can be done to improve people’s health in communities like yours.

The interview will take about 28 minutes. There is very low risk to participation. We will just ask you questions over the telephone. You don’t have to answer any question you don’t want to answer and you can stop the interview at any time.

Your answers are protected and private. And the results of the survey will only be reported for groups of people. No one will be able to identify you or your answers by looking at the results of the study.

After you complete the interview, I’ll ask you for your full name and your current address so that we can send you your choice of a $20 check or a $20 gift card to Walmart as a thank-you for your help.

Your contact information will be 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.

I’m now going to tell you how to contact our survey manager and the committee that makes sure the study is conducted in an ethical way. You may want to write this down in case you have questions later about the study or the rights you have for being part of the study.

If you have questions about the survey, please contact Brenna Muldavin, our survey manager. You can reach her by calling this toll-free number: {study-specific toll free number}.

Being part of this study gives you certain rights. If you have questions about your rights, please contact the Office of Research Protection which oversees this study. It is located at RTI International and can be reached by calling this toll-free number: 1-866-214-2043.

If you have any questions or you’d like me to repeat any of this information, please let me know.

*PAUSE* BEFORE CONTINUING, TO ENSURE FULL OPPORTUNITY TO ASK AND ANSWER QUESTIONS USING FAQs

IF NO OBJECTIONS, CONTINUE WITH INTERVIEW

{PRESENT FOR CELL SAMPLE ONLY}

Before we begin, I want to make sure this is a good time for you to talk and that you are in a safe and private place to use your cell phone. If at any point you want to go to another room or if you want to use a different phone where I could call you back, just let me know.

1 CONTINUE—LAUNCH TO CORE INSTRUMENT

2 CALL ALTERNATE NUMBER {GO TO ALTNUM}

ALTNUM. What number would you like me to use to call you back?

Consent Version: 03-08-2012 page 2 of 2

RTI IRB ID: 13033

RTI IRB Approval Date: [insert date of IRB approval – obtain from IRB office]