Form NHTSA Form 1302 NHTSA Form 1302 Informed Consent

OMB Control No. 2127-XXXX

Expiration Date XX/XX/XXXX

Appendix D

Informed Consent Form

This collection of information is voluntary and will be used to document voluntary consent to participation in the study. The results of the study will be used to develop programs designed to reduce the number of traffic-related injuries and deaths. A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2127-XXXX. Public reporting for this collection of information is estimated to be approximately 5 minutes per response, including the time for reviewing instructions, completing and reviewing the collection of information. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590.

Agreement to Participate in a Child Safety Seat Study

Informed Consent

You are invited to take part in a research study that investigates the methods people use to install child safety seats and how they secure children in the seats. We are also interested in how the participant feels about the overall experience. This study is sponsored by the Federal Government. Westat will provide the child safety seats, the vehicles they will be installed in, and the child-sized dolls.

Please read this consent form carefully. If you agree to participate in this study, please sign your name at the end of this form. You will receive a copy of this form for your records.

Purposes and Procedures. During this study, you will be provided with four different child-sized dolls representing different ages of children. You will be asked to select child safety seats for the different child-sized dolls, install the seats in different vehicles, and secure the dolls in the seats. You will also be asked to complete a brief questionnaire before and after each child safety seat installation. The entire session will last for approximately two hours. Only the researchers involved in the study will have access to any information collected during the study, the questionnaires, and any notes taken.

Participation. Participating in the research study is completely voluntary. You may agree or refuse to participate. If you agree to participate, you can stop at any time during the study. You will receive $75 upon completion of the study.

Confidentiality. No published reports of the research will identify any participants. Likewise, all information collected during the study is confidential to the fullest extent of the law and will not be presented in any form that identifies individuals. Any information gathered, including questionnaire data and notes, will be used only by staff who are involved in the project. All documents containing identifying information about you will be destroyed within three months of the end of this research project.

Risks. There are no anticipated risks in participating in this study.

Benefits. The findings of this study may provide information that will contribute to the safety of children when travelling in child restraint systems. There are no direct benefits to you.

Questions.

If you have any questions about this study please contact:

Dr. Doreen De Leonardis

(301) 315-5963

Westat

1600 Research Boulevard

Rockville, MD 20850

If you have any questions about your rights and welfare as a research participant, please call the Westat Human Subjects Protection office at 1-888-920-7631. Please leave a message with your full name, the name of the study, “Child Safety Seat Study”, and a phone number beginning with the area code. Someone will return your call as soon as possible.

Authorization. By signing this form, you certify that you have read this form and that you agree to take part in the study.

(If you accept these terms, please indicate your consent below)

I _____________________ (participant’s name) have received information about being involved in the Child Safety Seat Study study. I have read this form, I understand it, and my questions have been answered. I agree to participate in the study.

_____________________________ __________

Participant Signature Date

CONSENT FOR RELEASE OF VIDEO IMAGE AND AUDIO RECORDING FOR SCIENTIFIC AND EDUCATIONAL PURPOSES

I, __________________________, have consented to participate in a research project conducted by Westat called “Child Safety Seat Study.” As part of the informed consent form I have signed for my participation in this study, I have agreed to allow Westat staff to record video image data of me and audio data of my voice.

The purpose of this Consent for Release of Video and Audio Recording is to allow Westat or The National Highway Traffic Safety Administration to use the recording for educational purposes in the classroom, in professional conferences and presentations, and for other similar educational purposes.

I give my permission for Westat, to use my recorded video image and audio recording for the non-research purpose specified above. Under no circumstances will the video be released to the media or distributed on the Internet. If there is a request for the video to be given to the media, I understand I will be asked to sign another release. All facial images will be blurred or digitized so that the face is not recognizable.

I give Westat any rights I may have to the recordings.

I give up any right that I may have to look at, edit, or approve the recordings.

I release Westat and its employees from any claims that I may have related to the recordings or its use for the purposes referenced above.

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Name of Participant

________________________________________________

Signature of Participant

________________________________________________

Date

NHTSA Form 1302