Attachment B - ADVHOCaT Consent Form for Survey

OMB Control No.:xxxx-xxxx

Expiration Date: xx/xx/xxxx

ATTACHMENT B: Consent Form

Accomplishments of the Domestic Violence Hotline, Online Connections and Text (ADVHOCaT) Study

The National Domestic Violence Hotline (NDVH) [or loveisrespect (LIR)] is partnering with the Administration for Children and Families in the U.S. Department of Health and Human Services and George Washington University School of Public Health to conduct a research study to better understand the preferences of visitors to the NDVH [or LIR] website. We are surveying people who visit the website. Please read the information below to help you decide if you want to respond to the survey.

1. PURPOSE

We would like to ask you about your preferences and opinions related to the ways you can reach an advocate at the NDVH [or LIR].

2. PROCEDURES

If you agree, you will participate in a web-based survey. The survey should take about 2 minutes and 30 seconds to complete. During the survey, you will answer questions about your preferences and opinions related to the ways you can reach an advocate at the NDVH [or LIR], and some basic questions about yourself. We will not ask you any personally identifying information, like your name or address.

3. RISKS AND/OR DISCOMFORTS

There are no risks to participating in this survey. We will not ask you any personally identifying information, and your individual responses will not be shown to anyone outside of the study team.

4. VOLUNTARY PARTICIPATION

This collection of information is voluntary and will be used to better understand the services provided by the NDVH [or LIR]. You do not have to participate in this survey, and you can choose to stop the survey at any point.

5. PRIVACY

All information will be kept private to the extent permitted by law. Study reports will describe findings in general terms and because none of your personally identifying information will be collected, we will not know which specific individuals participated in the survey.

6. COSTS AND BENEFITS

There are no costs associated with the survey other than the time you spend completing it. You will not benefit personally from being involved in the study.

7. QUESTIONS

If you have any comments or concerns about participating in this study, you can contact Karen McDonnell, Principal Investigator at XXX-XXX-XXXX.

8. CONSENT

If you agree to participate, please click on the link below. If you do not agree to participate, please close this window by clicking the X at the top right.

NOTE: The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to better understand the services provided by the National Domestic Violence Hotline and loveisrespect. Public reporting burden for this collection is estimated to average 2.5 minutes, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is XXXX-XXXX and it expires on XX/XX/XXXX.

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Attachment B