Consent for Management

Attachment K

Informed Consent Form for Management

Consent to be in a Research Study Enhancing Dialogue and Execution of Dust Reduction Behaviors through Workgroup Communication Mine Management 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 ways that you share your knowledge of and/or responsibilities regarding how you implement and evaluate the health and safety management system at your mine, including specific practices that help mitigate safety/health risks, including overexposure to dust, over a period of time.
	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 any time for any reason without consequences to you. However, full participation will be helpful in informing what HSMS practices have the biggest influence on workers’ health/safety behaviors.
	What will I do?	You will be asked to participate in the following over a six-week time period: • An interview or focus group that will last no more than one hour that discusses how you currently oversee and manage your HSMS, including current dust control practices in place at the mine. • A follow-up interview or focus group that will take no more than 1 hour that discusses additional changes you’ve made in your HSMS practices and recommendations for future management of your system, including current/new dust control practices in place at the mine. Six to 12 months after the intervention ends, you may be asked to participate in a short checklist so we can gauge the effectiveness of the intervention at your mine. This checklist should take no more than 15 minutes to complete.
	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. If you participate in a focus group, there is a potential risk of a loss of confidentiality because you will be sharing your opinions with other members of this group. Although we are asking all participants in the group to keep information shared confidential, NIOSH cannot ensure this aspect of your confidentiality. Only NIOSH staff who are involved in collecting the information will have repeated access to your 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 will not directly benefit from the research but your answers could inform the ways that the industry utilizes their HSMS to reduce workplace exposure incidents.
	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.