Attachment F Adult Consent

ATTACHMENT F 
Consent Form 

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This page is intentionally blank. 

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Consent Form 
[LOGOS: HHS and IPSOS]
[PARTICIPANT ASKED SCREENER QUESTIONS PRIOR TO CONSENT]
Introduction
We would like you to take part in an online survey about your knowledge of male and female
fertility and your views on having children. About 3,000 young adults (18 to 29 years) in the
United States are being randomly selected and invited to take part in this study.
What is the purpose of this study?
The survey is being conducted by the U.S. Department of Health and Human Services (HHS)
Office of Population Affairs (OPA) to learn about what young men and women know about
human fertility and their views on having children.
What does my participation involve?
You will be asked to answer questions on an online survey. Please answer these questions on
your own and in private. The survey will take about 20 minutes to complete. You will be asked
about your:
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Knowledge of female and male fertility issues
Views on having children and intentions or goals for having children
Use of alcohol and cigarettes
Health insurance coverage and use of medical care services
Personal experiences with sex and pregnancy
Individual characteristics (examples: race, ethnicity, marital/relationship status)
If applicable, use of birth control methods

Can I change my mind about participating?
Yes. Participating in the survey is voluntary. While all of your answers are important to the
study, you may stop at any time. This will not affect your ability to participate in future surveys.
What are the possible benefits and risks of participating in the study?
Participating in this survey will not benefit you directly. However, your answers will be used to
better understand young people’s knowledge about fertility and views on having children, and to
provide them with information to help them make better decisions for themselves.
Taking this survey involves no risk of injury. You might feel embarrassed or uncomfortable
reading or answering one or more of the survey’s questions about pregnancy, sexual activity,
contraceptive use, or alcohol use. If any questions make you embarrassed or uncomfortable, you
may skip them or take a break. The only exception is that there are a few questions near the
beginning of the survey about your biological ability to have children, your sex as recorded on
your birth certificate, and your age. You must answer these questions in order for the survey to
proceed. If you choose to skip these items, you will not be able to complete the survey.

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How will you protect my privacy?
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The survey will not collect any information that can link you personally to your answers
(such as your name, address, e-mail address)
The personal identifying information (name, address, e-mail address) that you have already
shared as part of your membership in [KnowledgePanel OR YouthPulse Panel] will not be
shared with the study researchers or the study sponsor.
You will never be identified in any analysis, reports, or publications based on your
responses, and no one will try to sell you anything.

How will you keep my information confidential?
Ipsos has processes in place to keep answers to surveys confidential. You can answer the survey
questions on a computer, laptop, tablet, or smartphone. Although the guarantee of confidentiality
of data transmitted on the Internet cannot be absolute, your answers will be transmitted and
saved in a secure way to prevent viewing by anyone who does not have permission to do so, and
to prevent loss, alteration, or misuse of your answers.
A Certificate of Confidentiality has been obtained from the Federal Government for this study to
help insure your privacy. This Certificate means that the researchers may not disclose
information that may identify you, even by a court subpoena, in any federal, state, or local civil,
criminal, administrative, legislative or other proceedings. You should understand that a
Certificate of Confidentiality does not prevent you from voluntarily releasing information about
yourself or your involvement in this research. The Certificate cannot be used to resist a demand
for information from personnel of the United States Government that is used for auditing or
program evaluation by the agency (Office of Population Affairs) funding this study. The
Certificate of Confidentiality will not be used to prevent disclosure for any purpose you have
consented to in this informed consent document.
Who will see the information that I give?
Before the researchers and federal sponsor receive the data, Ipsos will remove information that
identifies you (like name or email) and combine your responses with the responses of other
people taking the survey. To be clear, the researchers will not receive identifying information
like name or email from Ipsos. When the researchers analyze and write up the combined results
of the survey to share with the federal sponsor and other researchers, they will write about the
combined information and not individual survey respondents. You will not be identified in any
published or presented materials. Sometimes there are opportunities for researchers to use data
from previous studies or to share data with each other if they are conducting similar research. For
these reasons, the study researchers or federal sponsor may use or share the combined data from
this study for future research. We will not ask for your additional consent for such research.
Will I receive anything for participating in this study?
[IF KP PANELIST: In appreciation for completing the survey, you will receive 5,000 points ($5
equivalent), which will be credited to your account.]
[IF YP PANELIST: In appreciation for completing the survey, you will receive $10.]

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Who can I contact if I have additional questions?
If you have any questions about taking part in this survey, you can contact the Panel Member
Support Center at the toll free number 1-800-782-6899 or send an e-mail to
[email protected].
If you have any questions about this study, you may call Dr. Christina Fowler at 1-800-334-8571
(extension 23447). If you have any questions about your rights as a study participant, you may
call RTI’s Office of Research Protections using toll-free number 1-866-214-2043.

By clicking on the box below, you give your consent to take part in this survey.

YES 

NO 

Yes, I agree to take part in this study.

No, I do not agree to take part in this study.

THANK YOU

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