Consent - Online Survey - Staff

Appendix M-2. Consent form for online survey with Z-CAN clinic staff

Introduction: The University of Puerto Rico and the Centers for Disease Control and Prevention (CDC) invite you to participate in a research survey.

The purpose of this survey is to gather information from non-physician Z-CAN staff from all Z-CAN clinics (around 130 clinics) about their experiences with Z-CAN and suggestions for improvement. We want to hear your candid opinions. Completing the survey will take about 15 minutes. You can skip any question that you do not want to answer, and you may stop the survey at any time.

Taking this survey is voluntary. If you decide not to take this survey, or if you don’t finish the survey, it will not impact your participation in the Z-CAN program.

Contact information is provided at the bottom if you have questions about your rights as a participant or concerns about the survey.

If you agree to take this survey, you will click on the “Agree” button below. The next screen will start the survey. If you feel uncomfortable with some of the questions, you do not have to answer, or you may stop the survey at any time.

You will not benefit personally from taking this survey. Summary information from you and other Z-CAN clinic staff will be used to make the Z-CAN program better.

Will the information I give be kept private?

The information you give us will be kept private and will be protected under the Privacy Act (System of Records Notice 09-20-0136). Your contact information will not be linked to your answers to the survey. When we present the results of this survey, we will not include any information that could identify you.

Who should I call if I have questions about this survey, have been harmed by the survey, or have questions about my rights as a research volunteer?

If you have questions or believe you may have been harmed by participation in the survey, please contact xxx at (xxx)-xxx-xxxx (toll free number) or xxx (email).

If you have questions about your rights as a participant in this survey, please contact the

Human Subjects Protections Office (IRB) at (787) 758-2525 or xxx (email).

Agree