Phone Consent Script

Appendix 19: Mode Effects Experiment – Phone Mode Consent Script

[INTRODUCTION SCRIPT:]

Hello, my name is _________. I am calling on behalf of the Maternal and Child Health Bureau at the U.S. Department of Health and Human Services. We are following up on a letter that was sent to your home regarding your participation in a research study about children’s health.

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. Your participation in this study will involve answering a series of questions about children’s health conditions. You must be 18 years of age or older to take part in this research study.

Can I ask you a few questions to see if you are eligible to participate in this study?

[INFORMED CONSENT SCRIPT READ AFTER DETERMINING ELIGIBLE CHILD(REN) IN THE HOUSEHOLD (PRIOR TO LAUNCHING TOPICAL QUESTIONNAIRE):]

Before we continue, I’d like you to know that taking part in this research is voluntary. You can stop at any time. You do not have to answer any questions you do not want to answer. 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. The questions that follow will take about [30/22] minutes to complete.

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.

In order to review my work, this call will be recorded and my supervisor may listen as I ask the questions. Only authorized staff members from NORC who are working on this project will have access to recordings. These recordings will be stored in secure NORC servers at all times. This recording will be erased once the project has ended.

[IF RESPONDENT OBJECTS TO RECORDING, STOP THE RECORDING AND EXPLAIN TO THE PARTICIPANT THAT THE INTERVIEW CAN CONTINUE WITHOUT RECORDING.]

Do you have any questions? INTERVIEWER: ANSWER ANY RESPONDENT QUESTIONS OR CONCERNS.

If you have any further questions after today’s interview, please contact us at [NORC 1-800 NUMBER]. If you have any questions regarding your rights as a study participant, please feel free to contact the chairman of the National Center for Health Statistics (NCHS) Research Ethics Review Board at [1-800 NUMBER].

Do you agree to participate in this study as I have described it?

[ADDITIONAL INFORMATION PROVIDED AT END OF SURVEY:]

If you have any questions or concerns about the study, please feel free to contact us at [NORC 1-800 NUMBER]. If you have questions about your rights as a survey participant, you may call the chairman of the National Center for Health Statistics (NCHS) Research Ethics Review Board at [1-800 NUMBER]. Thank you again.

[Flesh-Kincaid Grade Level: 8.9]