Att F_Consent Form

Attachment F

Appendix B. Informed Consent

Consent to be in a Research Study Assessing Safety and Health Hazards for Oil and Gas Extraction Workers Informed Consent
	Who is conducting the study?	NIOSH is a federal agency that studies worker safety and health. We are part of the Centers for Disease Control and Prevention (CDC).
	What is the purpose?	The purpose of this research is to learn more about the hazards faced by oil and gas extraction workers.
	What will I do?	You will complete a survey using the method of your choice: an electronic tablet, paper and pen, or worker interview. We will ask about your work, your health, your work-related injuries and motor vehicle crashes. At the end, researchers will ask all workers two final questions.
	When, where, for how long will I be needed?	You will complete the survey here on location and the whole process will last about 40 minutes.
	Are there any risks?	There is very little risk to you if you take part in this survey. However, if you tell us that you are in imminent danger at your worksite (i.e. that you are at risk of serious physical harm or death), we will need to report this to your employer. If we actually observe an imminent danger, we will need to report this to your employer and OSHA.
	Is my participation voluntary?	The study is voluntary. You may choose to be in the study or not. You may choose to answer any or all questions. You may drop out any time for any reason without consequences to you.
	What if I’m injured or harmed?	On-site emergency treatment will be provided. 911 will be called if needed. Medical care or compensation will not be provided. If harmed through negligence of a NIOSH employee, you might obtain compensation under Federal Law. If a NIOSH contractor is negligent, you can file a claim with that contractor.
	Will I be reimbursed or paid?	You will receive a $30 token of appreciation for completing the survey.
	Are there other benefits?	We may have information that is new to you about your safety and health at work. Also, your honest answers may increase knowledge about the health and safety issues facing all oil and gas extraction workers.
	Will my personal information be kept private?	NIOSH is authorized to collect your personal information and will protect it to the extent allowed by law. This survey is anonymous. Your personal information may be used for tracking but will be destroyed once the survey is complete at your location.
	Will I or anyone else receive study results?	The summary results for all workers at your site will be provided to your employer (if you are not taking this survey at a public place). You may also request the summary results.
	Who can I talk to if I have more questions?	For questions about the research study, contact the principal investigator, Kyla Retzer at [email protected] or 303-236-5934. For questions about your rights, your privacy, or harm to you, contact the Chair of the NIOSH Institutional Review Board (IRB) in the Human Research Protection Program, Angela Morley at [email protected] or phone 513-533-8591.