Consent Online Survey Z-CAN Women

Appendix Q. Consent form for online surveys with Z-CAN patients at 6 and 12 months

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 learn women’s opinions about their visits to Z-CAN clinics and about their use of birth control. This survey will be sent to about 3,200 women. You are being asked to take this survey because you were a patient at a Z-CAN clinic.

Taking this survey is voluntary. If you decide not to take this survey, or if you don’t finish the survey, you can still receive care at a Z-CAN clinic at no cost. The survey will take about 10 minutes.

If you agree to take this survey, click on the “Agree” button below. The next screen will start the survey. You may feel uncomfortable answering some questions. You can skip any question that you do not want to answer. You may stop the survey at any time.

You will not benefit personally from taking this survey. Information from you and other Z-CAN patients will be used to make the program better. At the end of the survey, you will be given a gift card worth $5 to thank you for your time.

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.

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