Att A_ Informed Consent Statement for Print Survey

Form approved

OMB No. 0920-0932

Expiration Date 07/31/2018

Attachment A

WORD OF MOUTH SURVEY

INFORMED CONSENT STATEMENT FOR PRINT SURVEY

The Centers for Disease Control and Prevention (CDC) and ICF, a consulting company, are conducting a health survey. The CDC is partnering with Health Talker, LLC, and [INSERT PARTNER NAME] to explore what the public knows about the Zika virus and the precautions you can take to reduce the chance of getting Zika when traveling. We will use this information for future communications.

You are being asked to participate. This survey should take about 10 minutes. A final report will be prepared for CDC with the results . Before you agree, please consider these conditions:

• Participation in this survey is completely voluntary. You may choose not to answer any questions, or stop the survey at any time.

• You can ask staff from [INSERT PARTNER NAME] any questions about this project before or after completing the survey.

You can also email the project team (Steve Simcox at [email protected] or Bethany Tennant at [email protected]) after completing the survey.

• Staff from ICF, CDC, HealthTalker, LLC, and [INSERT PARTNER NAME] may review your survey responses as they put everyone’s results together.

• Your responses will not be associated with your name or email address. Your name will not be used in the report.

• You may stop answering the survey at any time.

Participant Name:____________________________________ Date:_______________

Participant Signature:_________________________________

Contact Information: If you have any concerns about your participation in this survey or about the project, please contact Steve Simcox at [email protected] or Nicole Vincent at [email protected].