App M_Informed Consent

Appendix M

Informed consent form for boot outsole wear characteristics

Consent to be in a Research Study

Investigation of Boot Outsole Wear Characteristics

1 Who is conducting the study? The National Institute for Occupational Safety and Health (NIOSH) is a federal agency that studies worker safety and health. We are part of the Centers for Disease Control and Prevention (CDC).

2 What is the purpose? We would like to document the current state of your work boots including the make, model, tread design, and current tread wear.

3 Am I eligible to participate? You are eligible to participate if you are currently a surface mining employee.

4 What will I do? We will read you an informed consent form (this form). If you choose to participate, we will ask you to verbally indicate your agreement.

You will be asked to complete a brief survey about your current work boots and your recent slip, trip, and fall history. We will photograph your boots, then clean them, and 3-D scan them. They will be returned to you following the scan.

5 When, where, for how long will I be needed? We will ask you to complete the survey and scan your boots at a safe location at your mine site. We will need approximately 15 minutes of your time.

6 Are there any risks? This study poses no more than minimal risk to you. We will not be collecting your name or photographing your face. All information provided in the survey will be linked to a unique Participant ID that cannot be linked back to you.

7 Is my participation voluntary? Your participation in this study is voluntary. You may choose to be in the study or not.

8 What if I’m injured or harmed? On-site emergency treatment will be provided. We will follow all emergency procedures in place at your mine site. Medical care or compensation will not be provided by NIOSH researchers. If harmed through negligence of a NIOSH employee, you might obtain compensation under Federal Law.

9 Will I be reimbursed or paid? You will receive your regular salary while participating in this study. No additional compensation will be given for participating in the study.

10 Are there other benefits? There is no direct benefit to you for participating in this study, other than the satisfaction of assisting with research that will help document wear on work boots used at surface mining facilities.

11 What alternative procedures might benefit me? There are no alternative procedures for this study.

12 Will my personal information be kept private? We will collect some personal information such as age, gender and work history. However, only researchers on the research team will have access to the data and the collected data will be stored in a secured office at a NIOSH location. The personal information collected will be destroyed at the end of the study.

13 Will I or anyone else receive study results? If you would like a summary of the results of the study, please let us and your management know. We will provide a summary of results including an overall summary of data collected from several mine workers to your mine manager for distribution to you. We are unable to provide you with a summary of your own data. A summary of the information collected during this study is likely to be shared with members of the mining community at stakeholder meetings such as the annual meeting of the National Sand, Stone, and Gravel Association (NSSGA).

14 Who can I talk to if I have more questions? For questions about the research study, contact the principal investigator, Jonisha Pollard at [email protected] or 412-386-5220.

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 at 513-533-8591

15 Verbal consent Please indicate whether you would like to take part in the study by saying yes or no