Form approved
OMB No. 0920-0932
Expiration Date 07/31/2018
Attachment B
WORD OF MOUTH SURVEY
INFORMED CONSENT STATEMENT FOR ONLINE 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 email the project team (Steve Simcox at [email protected] or Bethany Tennant at [email protected] ) before 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.
Click on the button below to provide your consent in participating in the survey.
[Web Button “I agree”]
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].
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Erskine, Stefanie (CDC/OID/NCEZID) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |