Sample Consent Forms

Data Collection Through Web Based Surveys for Evaluating Act Against AIDS Social Marketing Campaign Phases Targeting Consumers

OMB No. 0920-0920

Sample Participant Consent Form

READING LEVEL 7.2 (ASSESSED BY FLESCH-KINCAID)

Introduction and Purpose:

You have been asked to take part in a survey as part of a research study. The purpose of the interview is to hear your opinions about [INSERT TOPIC]. e-Rewards and [NAME OF CDC EVALUATION CONTRACTOR], located in [STATE], are conducting the survey. The interview is sponsored by the Centers for Disease Control and Prevention (CDC).

Procedures:

The survey is about [INSERT TOPIC] and should take approximately [INSERT MINUTES] to complete.

Risk/Discomforts and Right to Refuse or Withdraw:

You might feel embarrassed or upset by some questions in this survey. You can decline to answer any questions for any reason. You can stop the survey at any time.

Benefits:

There is no direct benefit to you for being in this interview. However, you may learn more about [INSERT TOPIC].

Privacy:

Your responses will be kept private to the extent allowable by law. No identifying information will be included on the survey.

Token of Appreciation:

We will give you [INSERT REWARDS AMOUNT] as a token of appreciation for completing the survey.

It is your choice to complete the survey. You can choose not to talk about any topic. You can stop taking the survey at any time.

Persons to Contact:

If you have questions about the interview, you can call [NAME OF CDC EVALUATION CONTRACTOR PROJECT DIRECTOR] at 1-XXX-XXX-XXX, extension XXXX. She/he can be reached between X a.m. and X p.m., Eastern Standard Time, Monday–Friday. If you have questions about your rights as a participant, you can call [NAME OF CDC EVALUATION CONTRACTOR IRB CONTACT] of [NAME OF EVALUATION CONTRACTOR’S] Office of Research Protection toll-free at 1-XXX-XXX-XXXX.

Consent:

Please choose one to continue with the survey:

I have read this consent form and agree to participate in the survey.

I have read this consent form and do not want to participate in the survey

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