Attachment F
Consent Form: MT General Population Sample
What is this survey about? What will you ask me to do?
This is a screener survey to collect demographic information from some Mechanical Turk workers. We will ask you to answer questions about yourself. If your background matches the needs of our survey, we will send you another Human Intelligence Task (HIT) directly. The HIT will be a request to complete a full survey about problems in relationships between intimate partners.
This screener survey will take about 5 minutes. You will receive 10 cents for doing the screener survey. If your background matches the needs for our full survey, you will receive up to 5 dollars for taking the full survey.
Who is conducting the screener survey?
The American Institutes for Research (AIR) is conducting this survey. AIR is a research organization based in Washington, DC. The survey is funded by the Centers for Disease Control and Prevention (CDC), a government agency.
Do I have to take the screener survey?
No. It is your choice whether to do the screener survey or not. If you decide to do the screener survey, you can stop taking it at any time. You do not have to answer any questions that you don’t want to. There are no penalties and your approval rating will not be affected if you decide to skip any questions, if you do not complete the screener, or if you chose to start the screener survey and change your mind later.
What are the risks and benefits if I take the screener survey?
There are few risks to taking the screener survey. You may feel uncomfortable answering some of the questions on the survey. You may, skip questions that you are uncomfortable answering or stop taking the survey at any time.
The benefits to taking the screener survey are that if your background matches the needs of our full survey, you will have the chance to earn up to 5 dollars for completing the full survey in another HIT.
How will you protect my privacy?
We know how important it is to keep your information private. We will take all steps to keep your information confidential. Your answers will only be identified by a code number given to you by AIR. Your WorkerID, which will only be used to send you the next HIT if you are eligible, is only known by project team researchers. Your WorkerID will not be linked with any of your answers. Additionally, results from this screener survey will only be reported for groups of participants. We will never report results about specific people.
What if I want more information?
If you have additional questions or concerns about this survey, please contact the director of the survey at AIR, Melissa Scardaville, Ph.D. at (404) 260-1046.
If you have concerns or questions about your rights as a participant, contact AIR’s Institutional Review Board (which is responsible for the protection of people taking this survey) toll free at 1-800-634-0797 or c/o IRB, 1000 Thomas Jefferson Street, NW, Washington, DC 20007.
Please click the “Agree” button if you agree to take the screener survey
Clicking the “agree” button means that you are agreeing to take this screener survey. This means that you have read and understood the information on this form and you are willing to take the survey under the conditions we described.
Understanding Relationship Dynamics and
Conflict Survey
Thank you for coming today. Please read (or ask me to read) the information below about our survey. Be sure to ask if you have any questions. If you are willing to take part in the survey, please sign your name at the bottom and give the form back to us.
What is this survey about? What will you ask me to do?
This survey is about problems and violence that sometimes happen in relationships between partners, such as boyfriends and girlfriends or husbands and wives. We will ask you to answer questions about yourself and your relationships.
You are one of about 1,750 people taking this survey. Everything we learn will help us think about ways to understand violence in relationships.
This survey will take about 75 minutes. You are welcome to help yourself to one of the snacks we have here. You will also receive 25 cents on your commissary card if you decide to participate.
Who is giving the survey?
The American Institutes for Research (AIR) is giving this survey. AIR is a research organization based in Washington, DC. The survey is funded by the Centers for Disease Control and Prevention (CDC), a government agency.
Do I have to take the survey?
No. It is your choice whether to do the survey or not. If you decide to start the survey, you can stop taking it at any time. You do not have to answer any questions that you don’t want to. There are no penalties or punishments if you choose not to take the survey. There are no penalties or punishments if you chose to take the survey and change your mind later.
What are the risks if I take the survey?
You may feel uncomfortable answering some of the questions on the survey. Remember, you can, at any time, skip questions that you are uncomfortable answering or stop taking the survey.
Some questions ask about your thoughts, experiences, or illegal activities, including violence towards other people. We know that if other people found out about your answers, it can be embarrassing or cause problems with your job and in your relationships. Please know that anything you share will be kept private and never linked to your name.
There is one exception. If you share information about child abuse or abuse of an elderly or disabled person that is currently happening, we must report this to the proper authorities. We will not ask you to tell us about this and we suggest that you do not share this information during the survey.
What are the benefits if I take the survey?
Please know that taking this survey will not affect your case. It will neither help nor hurt your case in any way.
The benefits to taking the survey are that you will help add to what is known about violence in relationships. This could help form better programs that address relationship violence.
How will you protect my privacy?
We know how important it is to keep your information private. We will take all steps to keep your information confidential. Your answers will have a code number given to you by AIR. We will not link your name or Facility ID number with anything you say. Additionally, results from this survey will only be reported for groups of participants. We will never report results about specific people.
This project has a Certificate of Confidentiality from the CDC. This means that we cannot and will not share any information about you in any legal situation. Any documents that could identify you will be kept in a securely locked place.
What if I want more information?
Please ask us today if you have any questions. If you have additional questions or concerns about this survey, please contact the director of the survey at AIR, Melissa Scardaville, Ph.D. at (404) 260-1046.
If you have concerns or questions about your rights as a participant, contact AIR’s Institutional Review Board (which is responsible for the protection of people taking this survey) toll free at 1-800-634-0797 or c/o IRB, 1000 Thomas Jefferson Street, NW, Washington, DC 20007.
Signature of Subject or Legally Authorized Representative
I have read (or someone has read to me) the above information. I have been given the chance to ask questions, and my questions have been answered to my satisfaction. I have been given a copy of this form.
Please check the appropriate box below to indicate if you agree to participate in this research:
___ I agree to take the survey
___ I would like to talk with someone from the research team before making my
decision.
___ I do not agree to take the survey
Your signature:_______________________ Date:______________________
Print your name:_____________________ Appointment time:_______________
Understanding Relationship Dynamics and
Conflict Survey
What is this survey about? What will you ask me to do?
This survey is about problems and violence that sometimes happen in relationships between intimate partners. We will ask you to answer questions about yourself and your relationships.
You are one of about 1,750 people taking this survey. Everything we learn will help us think about ways to prevent violence in relationships.
This survey will take about 50 minutes. You will receive 3 dollars for doing the survey and a bonus of 2 dollars if you answer at least 90% of the questions.
Who is conducting the survey?
The American Institutes for Research (AIR) is conducting this survey. AIR is a research organization based in Washington, DC. The survey is funded by the Centers for Disease Control and Prevention (CDC), a government agency.
Do I have to take the survey?
No. It is your choice whether to do the survey or not. If you decide to do the survey, you can stop taking it at any time. You do not have to answer any questions that you don’t want to. There are no penalties and your approval rating will not be affected if you decide to skip any questions. There are no penalties and your approval rating will not be affected if you chose to start the survey and change your mind later.
What are the risks if I take the survey?
You may feel uncomfortable answering some of the questions on the survey. Remember, you can, at any time, skip questions that you are uncomfortable answering or stop taking the survey.
Some questions ask about your thoughts, experiences, or illegal activities, including violence towards other people. We know that if other people found out about your answers, it can be embarrassing or cause problems with your job and in your relationships. Please know that anything you share will be kept private and never linked to your name.
What are the benefits if I take the survey?
The benefits to taking the survey are that you will help add to what is known about violence in relationships. This could help form better programs to prevent relationship violence.
How will you protect my privacy?
We know how important it is to keep your information private. We will take all steps to keep your information confidential. Your answers will only be identified by a code number given to you by AIR. Your WorkerID, which was only used to send you the Human Intelligence Task (HIT), is only known by project team researchers. Your WorkerID will not be linked with any of your answers. Additionally, results from this survey will only be reported for groups of participants. We will never report results about specific people.
This project has a Certificate of Confidentiality from the CDC. This means that we cannot and will not share any information about you in any criminal courts.
What if I want more information?
If you have additional questions or concerns about this survey, please contact the director of the survey at AIR, Melissa Scardaville, Ph.D. at (404) 260-1046.
If you have concerns or questions about your rights as a participant, contact AIR’s Institutional Review Board (which is responsible for the protection of people taking this survey) toll free at 1-800-634-0797 or c/o IRB, 1000 Thomas Jefferson Street, NW, Washington, DC 20007.
Please click the “Agree” button if you agree to take the survey
Clicking the “agree” button means that you are agreeing to take this survey. This means that you have read and understood the information on this form and you are willing to take the survey under the conditions we described.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Huang, Alison |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |