Informed Consent Form

Research on Evacuating Persons with Mobility Impairments

Questionnaire for Building Occupants

Engineering Laboratory

National Institute of Standards and Technology

INFORMED CONSENT FORM

You are being asked to participate in a study titled “Research on Evacuating Persons with Mobility Impairments” conducted by the Fire Research Division at the National Institute of Standards and Technology (NIST) within the Department of Commerce. NIST is performing a study on elevator usage in your federal building. The focus of this research effort is two-fold: 1) to gain an understanding of how building occupants, especially those with mobility impairments, currently evacuate multi-story buildings in the United States during fire emergencies, and 2) to learn about the concerns of occupants on using elevators during fire evacuations. Your responses will provide guidance to designers and building managers on aspects of fire evacuation that comfort and concern occupants with mobility impairments and on how to improve elevator design and usage during fire emergencies.

This study poses minimal risk to you. Your participation in this study is voluntary and without compensation. There are no penalties if you choose not to participate. You do not have to provide a reason for choosing not to participate. You may refuse to answer any specific question on the questionnaire. In order to provide assurance of confidentiality, the NIST researchers will not associate participant names and contact information (when provided by the respondent) with responses. Instead, a number will be given to each set of questionnaire data, stored in one secured location, and the same number will be given to the corresponding set of contact information, located in a different secured location. A key that identifies the number that corresponds to each respondent will be kept in a third secured location, not to be shared with anyone outside of the project team.

Although there are no direct benefits to you personally, your participation will provide invaluable information that will assist this study and related efforts to provide benefits to the nation in the form of improved life safety in the face of future building fire emergencies.

Any personal information you provide will be kept confidential to the extent permitted by law, including the Freedom of Information Act (FOIA) (5 U.S.C. 552) and the Privacy Act (5 U.S.C. 552a). Any reports that are produced based on information provided in the questionnaire will not release any personally identifiable information, nor will any specific building be identified. The Office for Human Research Protections (of the U.S. Department of Health & Human Services), NIST, the Department of Commerce and any other Federal officials (e.g. the DOC Office of the Inspector General), as appropriate, have the right to inspect study records, if deemed necessary.

By clicking the button below, you agree to the following statements:

• I have read this informed consent form

• I know the possible risks associated with participating in this study

• I know that this study is voluntary and that I may end my participation at any time.

For questions regarding your rights as a human subject, please contact Richard Cavanagh, Chair, NIST Institutional Review Board (IRB), at (301) 975-4447 or [email protected]. Any research-related injury during the study should be reported to the NIST Principal Investigator, Kathryn Butler, at (301) 975-6673 or [email protected].

NOTE: This questionnaire contains collection of information requirements subject to the Paperwork Reduction Act (PRA). Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be subject to penalty for failure to comply with, a collection of information subject to the requirements of the PRA, unless that collection of information displays a currently valid OMB Control Number. The estimated response time for this questionnaire is 15 minutes. The response time includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this estimate or any other aspects of this collection of information, including suggestions for reducing the length of this questionnaire, to the National Institute of Standards and Technology, Attn., Kathryn Butler, [email protected], 301-975-6673.

YOU MAY CHOOSE TO PRINT THIS PAGE TO KEEP A COPY OF YOUR CONSENT FOR YOUR RECORDS.

[NOTE: After the participant clicks the button shown above, the following information will appear on the screen.]

“Click the “Next Page” button below to begin the Research on Evacuating Persons with Mobility Impairments Questionnaire for Building Managers.

Please contact the NIST Principal Investigator, Kathryn Butler, if you have any further questions about this study:

Kathryn Butler, Ph.D.
Fire Research Division/Engineering Laboratory
National Institute of Standards and Technology
100 Bureau Drive, Gaithersburg, Maryland 20899-8662
Phone: 301-975-6673

E-mail: [email protected]

For questions regarding your rights as a human subject, please contact Richard Cavanagh, Chair, NIST Institutional Review Board (IRB), at (301) 975-4447 or [email protected]. Any research-related injury during the study should be reported to the NIST Principal Investigator, Kathryn Butler, at (301) 975-6673 or [email protected].

YOU MAY CHOOSE TO PRINT THIS PAGE TO KEEP A COPY OF THE CONTACT INFORMATION FOR YOUR RECORDS.

NIST IRB Approved: _________________ 2