consent

Attachment 4:

informed consent for survey

You are part of select group of women who participated in a unique program, and we would like to know how or if it has helped you. To that end, the Office on Women’s Health (OWH) is working with NORC at the University of Chicago to evaluate the Women’s Health Leadership Institute (WHLI) to determine the intermediate and long-term impacts and outcomes of the WHLI training. This evaluation will enable OWH to demonstrate the long-term effectiveness of the WHLI and further improve the training program. Your input is invaluable and this project cannot succeed without your help. As a token of our appreciation, we will provide you with a $10 Amazon gift card for completing this survey.

We value your time. Completing the survey will take approximately 25 minutes. There are no foreseeable risks to your participation. However, your participation in this study is completely voluntary, and you may skip questions and stop the survey at any time without any adverse consequences. Whether or not you choose to participate in the study, or decide to withdraw at any point, will not affect you in any way. All information collected will be kept private to the extent possible by law. While your responses will be used in a final report for the Office on Women’s Health, you and your organization will not be identified. Please click below to begin the survey. If you have any questions about your rights as a participant in this research study, please call the NORC IRB Manager by toll-free phone number at (866) 309-0542. If you have any questions about this project, please feel free to call 1-800-604-2698 or e-mail [email protected] for assistance.

By clicking the “begin survey” button below, you are consenting to participate in this research study.

• Yes

• No