Web Consent Script

Appendix 16: Mode Effects Experiment – Web Mode Consent Script

[TEXT DISPLAYED ON LOG-IN PAGE PRIOR TO LAUNCHING SCREENER QUESTIONNAIRE:]

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. You must be 18 years of age or older to take part in this research study.

We will do our best to protect the confidentiality of all the information we collect from you. We will not give out your information to third parties. However, no one can guarantee complete confidentiality for data that is sent over the Internet. Participation is voluntary and you will be able to skip any of the questions.

If you have any questions or concerns:

• Contact us at [NORC 1-800 NUMBER] or email us at [EMAIL] 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

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

Before we continue, we’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 survey questions that follow will take about [30/22] minutes to complete.

We will do our best to protect the confidentiality of all the information we collect from you. We will not give out your information to people other than the researchers involved in the study. However, no one can guarantee complete confidentiality for data that is sent over the Internet.

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] or email us at [EMAIL] 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 of this survey indicates that you have read this information and consent to take part in this research study.

[ADDITIONAL INFORMATION PROVIDED AT END OF SURVEY:]

Thank you for completing the survey. If you have any questions or concerns:

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

• Contact the chairman of the Research Ethics Review Board at [1-800 NUMBER] with any questions regarding your rights as a study participant

[Flesh-Kincaid Grade Level: 8.9]