Sample Intro and Consent

Attachment J: Sample Introduction and Consent Script

Community Assessment for Public Health Emergency Response

Hello, we are ________________________and_____________________________ with the [insert name of local or state health department]. We have some information we would like to leave with you related to [topic of material (e.g., some health concerns, carbon monoxide, proper cleanup)] following the recent [disaster (e.g., hurricane, ice storm, tornado)].

A lso, we are talking to residents in [name of county(s)] county who have been affected by the [disaster] about their health and other needs so that we can get a better idea of what kind of help people need. Your house is one of many that have been randomly chosen to be in this survey. If you agree to participate, we will ask you some general questions about your house and the people who live there and questions about certain kinds of environmental hazards. The survey should take no more than [time a mock interview using the final questionnaire and insert time here] to complete. We will keep your answers private. You can refuse to take part in the survey or refuse to answer any of the questions. Nothing will happen to you or your household if you choose not to take part in the survey.

You may have questions about this survey. If so, you can ask anyone here right now. If you would like to confirm that we were sent by the [insert name of local or state health department], you can call [insert contact person name, department, and phone number].

Are you willing to participate in this survey?

[WAIT FOR RESPONDENT TO CLEARLY ANSWER YES OR NO].

Thank you very much for your time