Consent Form

 Informed Consent Form
OMB#: 0925-0643 Exp. Date:10/31/2017 

Identification of Project

Medical Rehabilitation Research Network CUSTOMER SATISFACTION SURVEY.

Statement of Age of Subject
I state that I am at least 18 years of age and wish to participate in a survey being conducted by the Eunice Kennedy Shriver Nation Institute of Child Health and Human Development, Bethesda, MD 20892.

Purpose
The purpose of this survey is to understand how satisfied MRRIN investigators receiving Pilot Project awards are with the services provided by the centers granting the pilot funds.

Procedures
Participants will be asked to access a web-based questionnaire and complete the questionnaire by a specific date. The total time involved, including instructions, will be no more than 10 minutes.

Confidentiality
All information collected in this survey will be kept secure to the extent permitted by law. I understand that the data I provide will be grouped with data that others provide for the purpose of reporting and presentation, and that my name will not be used.

Risks
I understand that the risks of my participation are expected to be minimal in nature. 

Benefits, Freedom to Withdraw, & Ability to Ask Questions
I understand that this survey is not designed to help me personally but that the investigators hope to learn about the user’s overall satisfaction with the MRRIN Pilot Project Program. The survey population will include individual recipients of MRRIN Pilot Project awards. I am free to ask questions or withdraw from participation at any time and without penalty.

Contact Information of Investigators
Name: Jennifer Guimond, PhD
Office: Office of Science Policy, Analysis and Communication (OSPAC)
National Institute of Child Health and Human Development (NICHD)
Telephone: 301-594-3866 
Email: [email protected]