App E_Study Consent Form

Appendix E

Cognitive Laboratory Study Consent Form

Participant Informed Consent

The CDC is doing a research study on health and injuries. The results of the survey will help the CDC guide national policies. Right now we’re just testing how well the questions work.

This research study is being conducted by RTI in collaboration with the Centers for Disease Control and Prevention or CDC. You are one of up to 30 participants who will test these questions. You were chosen to participate because you are over 18 and may have had some experiences with the research topics we are studying.

This interview will be conducted over the telephone and will take about 1 – 2 hours. After I finish explaining the study to you, my colleague will call you on the telephone in this room and conduct the interview with you over the speaker phone. They will ask questions about your experiences with health and injuries. There may be some questions about physical injuries, harassing behaviors, and unwanted sexual activity. As much as possible, try thinking out loud as you answer these questions. We will ask some follow-up questions to find out how you arrive at your answers. Please let us know if a question doesn’t make sense or makes you feel uncomfortable. I will be recording your responses and any problems with the questions. When we are done with the interview, I will give you $40.00 in appreciation for your time.

It is important to understand that taking part in this interview is entirely voluntary. There are no benefits to you for participating. Choosing whether or not to participate will not affect any benefits you may be receiving. One risk is that some of the questions may be upsetting to some people. You can skip any question that you do not want to answer. There is no penalty for skipping any question or any part of the interview. Please do not mention anyone by name during the interview process.

In order to make the best use of our findings, we ask you to allow us to audio-tape your interview. The tape will only be heard by authorized people who are working on this project. This includes the project staff here at RTI and the project client at the CDC. The only purpose of tape-recording is to allow us to review the interview in order to hear how well the survey questions work. We will destroy the tape at the end of the study. If at any time you would rather that the interview not be taped, just tell the interviewer and the interview will no longer be taped. Federal law requires us to keep your answers confidential and to use your answers only for research purposes, according to the Confidential Information Protection and Statistical Efficiency Act of 2002. Your answers to these questions will not be linked with your name. There are, however, some exceptions to our promise of confidentiality. If you tell us that you are in immediate danger or that you intend to harm yourself or someone else, or if there is any mention of child abuse, we may need to inform the appropriate authorities according to state and local law.

If you have any questions about the study, you may call Lisa Carley-Baxter at 919-485-2616. If you have any questions about your rights as a research participant in this study, you may contact RTI's Office of Research Protection at 1-866-214-2043.

I agree to participate in this interview.……………………………………………………..□ Yes……..□ No

You have my consent to record the interview by audiotape………………………………□ Yes……..□ No

Participant Number: ___

Interviewer Name: __________________________________ Date: __________________

Interviewer Name signifies that respondent has given verbal consent to participate.