Example Manager Informed Consent

Form Approved

OMB No. 0920-0792

Exp. Date 02/28/2015

Attachment 7: Example of EHS-Net Manager Informed Consent

Public reporting burden for this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: CDC/ATSDR Information Collection Review Office, MS D-74; 1600 Clifton Road NE, Atlanta, Ga. 30333; ATTN: PRA (0920-0792)

Let me give you a little background on why I’m here and what we are going to be doing. I’m working with __________________ (state health department) on a research project designed to help us better understand managers’ and workers’ food safety knowledge and attitudes and restaurant policies and practices. Your restaurant was picked at random to be in this project. Participation in this study is voluntary. You can choose to stop at any time. If you don’t want to be part of the study or if you change your mind later, nothing will happen to you. Whether you are part of the study or not will not affect your restaurant’s score on any health inspection.

Having said that, I need to let you know that if at any time during my visit I see something that is an imminent health hazard, such as no power, no water or sewage on the floor, I will need to stop the study and report the problem to your local health department.

I’m going to ask you some questions about this restaurant’s policies and practices, and your food safety knowledge. If any of the questions make you uncomfortable you can choose not to answer them. The information I collect today will be combined with information from other restaurants in various states and analyzed. Your name and your restaurant’s name will not be recorded on the data collection form, nor will they be included in any reports.

The information you provide will be valuable in helping us understand the difficult issues restaurants face, so we ask you to be as open and honest as possible.

After our interview, I’d like to observe your kitchen for a while. I’d also like to talk to one of your food workers for about ten minutes, if possible. It can be a worker of your choosing, a worker that you feel you can spare for a few minutes, but it needs to be someone who works in the kitchen, has food handling responsibilities and can speak English fairly well.

Do you have any questions?

If you have any questions at a later time, you can contact: (Local Contact Name). (If have card) My information is on this card.