Informed Consent to Participate in a Leading Indicbenchmarking Research Project

Attachment G:

Informed Consent

Form Approved

OMB No.0920-0949

Exp. Date xx/xx/xxxx

INFORMED CONSENT TO PARTICIPATE IN A LEADING INDICBENCHMARKING RESEARCH PROJECT

We would like to invite you to participate in a project being conducted by the University of Texas School of Public Health (UTSPH). The project is sponsored by the National Institute for Occupational Safety and Health (NIOSH) and the Ohio Bureau of Workers’ Compensation (OBWC).

The project’s purpose is to identify safety and health practices that reduce workers’ compensation claims and costs for Ohio wholesale and retail trade companies. Identifying safety and health practices associated with reduced claims and costs allows employers to better manage safety and health for improved outcomes. If you agree to participate:

• You will be asked to complete a 12 minute survey about your company’s safety and health practices and a little about your work background and general company information.

• Individual surveys will not be shared with OBWC.

• The survey data will be compared to past and future workers’ compensation data. Company data will be anonymously pooled with other companies to identify the safety and health practices most likely to reduce workers’ compensation losses.

• There is little anticipated risk to you from filling out the survey. Your name and your company’s name will not be disclosed in any UTSPH, NIOSH or OBWC reports. Data will be treated in a secure manner and will be protected to the extent provided by law.

• We will ask you to complete a follow-up survey in one year.

Your participation is voluntary and you may withdraw at any time without consequence to you or your company.

The new information gained is expected to improve our understanding of the safety and health practices that best prevent injuries and illnesses. There are no immediate direct benefits to you personally from participating.

If you have questions about this study, contact David Gimeno at the University of Texas School of Public Health (UTSPH). If you have questions about your rights as a member of this study, contact UT Compliance Hotline at 1-888-472-9868, www.uthouston.edu/compliance/reporting-issues/hotline.htm, or NIOSH at 513-533-8222, [email protected].

Thank you,

David Gimeno, Ph.D. UTSPH 7411 John Smith Drive, Suite 1120 San Antonio, TX 78229 210-562-5500 [email protected]

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