Mail Consent Script

Appendix 12: Mode Effects Experiment – Mail Mode Consent Script

This research study is being conducted to look at ways to improve survey questions. These questions will be used to gather information on children’s health. This study is funded by the Maternal and Child Health Bureau at the U.S. Department of Health and Human Services. Your participation in this study will involve answering a series of questions about children’s health conditions. The survey will take about [30/22] minutes to complete. You must be 18 years of age or older to take part in this research study.

While there is no direct benefit to you for participating in this survey, your feedback may help us develop better ways of understanding the health and well-being of children. There are no risks in participating in this research beyond those experienced in everyday life. Your participation in this study is entirely voluntary. You can stop at any time. You do not have to answer any questions you do not want to answer.

Your participation in this research is confidential. You will not be personally identified in any report of the study findings. Your name will not be associated with any information you provide.

The U.S. Department of Health and Human Services (DHHS) gave this study a legal document, called a Certificate of Confidentiality. This means that the Study cannot be forced by a court order or subpoena to give out information that might identify you in any court. We will only release your information if you request it.

Federally funded projects such as this one are sometimes audited or evaluated by the United States Government. If that happens, we cannot use the Certificate of Confidentiality to protect your information from staff conducting the audit or evaluation.

If you have any questions or concerns:

• Contact us at [NORC 1-800 NUMBER] for any questions about the study

• Contact the chairman of the National Center for Health Statistics (NCHS) Research Ethics Review Board at [1-800 NUMBER] with any questions regarding your rights as a study participant

Your completion and return of the survey indicates that you have read this information and consent to take part in this research study.

[Flesh-Kincaid Grade Level: 8.9]