Consent for Workers

Attachment J

Informed Consent Form for Workers

Consent to be in a Research Study Enhancing Dialogue and Execution of Dust Reduction Behaviors through Workgroup Communication Individual Worker Consent Form
	Who is conducting the study?	The National Institute for Occupational Safety and Health (NIOSH)/ the Office of Mine Safety and Health Research (OMSHR) is a federal agency that studies worker safety and health. We are part of the Centers for Disease Control and Prevention (CDC).
	What is the purpose of the study?	We want to learn, from your perspective, your perception of the organizations’ management of health and safety regarding communication about dust exposure and other risks on the job– and how these practices influence your safety/health behaviors.
	Is participation voluntary?	Yes, the study is voluntary. You can choose to be in the study or not. You can choose to answer any or all questions. You can drop out at any time for any reason without consequences to you. However, full participation may help inform what actions reduce your exposure to dust, helping to prevent the onset of dust-related diseases.
	What will I do?	You will be asked to participate in several data collection efforts over a six-week time period. You have the option to accept or decline participation in any and all of the following data collection activities: • An individual pre-assessment survey that is followed by a focus group meeting with your workgroup that involves completing discussion worksheets about dust exposure and reduction behaviors. This will take no more than 1.5 hours. • A focus group meeting with your workgroup that involves completing discussion worksheets about dust exposure and reduction behaviors. This will take no more than one hour. • An individual post-assessment survey that is followed by a focus group meeting with your workgroup about changes in behaviors that affect dust exposure. This will take no more than 1.5 hours.
	Where, when, for how long?	We will collect information in a room, on the surface, behind closed doors to protect your confidentiality. The time requested for each activity is listed in the above box.
	Are there any risks?	The questions in the study pose minimal risk to you, if you participate. We are not collecting your name. There is a potential risk of a loss of confidentiality if you decide to share information from your CPDM with other individuals. NIOSH cannot ensure this aspect of your confidentiality. Only NIOSH staff who are involved in collecting the information will have repeated access to your data and responses. In any public release of results, no data will be disclosed that could be used to identify specific individuals. The only physical risks during this study include potential slips, trips, or falls when coming into the meeting room or meeting area to complete data collection activities.
	What if I am injured or harmed?	On-site emergency treatment will be provided. 911 will be called if needed. Medical care or compensation will not be provided. If harmed through negligence of a NIOSH employee, you might obtain compensation under Federal Law.
	Will I be reimbursed or paid?	You will not be paid or reimbursed for participating because you will be participating during your normal work hours.
	Are there other benefits?	You may directly benefit from the research by learning about specific behaviors that could reduce your exposure to repirable coal mine dust and inform ways to mitigate other health/safety issues at the workplace.
	Will my personal information be kept private?	We are not collecting your name. NIOSH is authorized to collect and keep your personal information and we will protect it to the extent allowed by law. There are conditions under the Privacy Act where release of your information is allowed. To learn more, contact the people listed below.
	Will I or anyone else receive study results?	Publications/reports/trainings will be produced based on the study results and contain suggested practices to improve the ways mine sites communicate about health and safety problems, including dust exposure. This will be available on the NIOSH website: http://www.cdc.gov/niosh/mining.
	Who can I talk to if I have questions?	For questions about the research study, contact Emily Haas, principal investigator, at [email protected] or (412) 386-4627. For questions about your rights, your privacy, or harm to you, contact Gail McConnell, Acting Chair of the NIOSH Human Research Protection Program, at [email protected] or (412) 386-4950.