Cognitive Testing Informed Consent

Attachment I: CONSENT FORM

Westat is conducting this research for the Centers for Disease Control and Prevention (CDC). We are developing a survey about health and injuries that asks questions about physical injuries, harassing behaviors, and unwanted sexual activity. The purpose of today’s interview is not to collect data from you, but rather to test the survey questions to ensure that the questions make sense, are easy to answer, and that everyone understands the questions in the same way. Your feedback will help us improve the survey. The survey asks about different types of experiences that you may have had. The interviewer will administer the survey with you, and will ask you follow-up questions to explore how you interpreted the questions and how you came up with your answers.

The interview will last about one hour. You will receive $40 cash as a token of our appreciation at the end of the interview. Your participation is completely voluntary. You may stop at any time, and you can skip any questions you do not wish to answer.

Some of the language in the survey is explicit, but it is important that we ask the questions this way so it is clear what we mean. The questions we ask are detailed and some people may find them uncomfortable.

(CATI: Please make sure you are in a quiet and private place for this interview. It is best that you are in a place where no one else can hear you talking. If at any time during the interview someone else begins listening to the conversation, just let me know and we can find another time to complete the interview.)

There are no known benefits for you to take part, but your answers will help us improve the survey. There is a risk that some of the questions that we will ask you to talk about are about private and sensitive things that may bother you. If you become upset during the interview or want to stop the interview at any time, please let the interviewer know. The interviewer will provide you with a list of resources at the end of the interview that you can use to help you.

All information obtained during this study will be treated as confidential, as required by law, and will only be used to develop and improve the questionnaire. We will not share your answers with anyone outside of the research team. The one exception is that if you express that you are a danger to yourself or to others. If that happens, in order to help protect your safety and the safety of others, we would report this to the appropriate healthcare or law enforcement agencies.

Members of the research team may observe the interview so they can directly hear your comments about the survey questions. They are required to keep any information they receive as part of these observations confidential and are not to discuss the contents of them with anyone outside of the research team. In order to have a complete record of all comments, we would like to audio and video record the interview. Recordings allow us to carefully review the discussion and ensure that we accurately capture your thoughts and opinions. If you choose not to have your interview recorded, that’s okay, but we would like to take notes to make sure that we don’t miss anything that you say. We will destroy the recordings and notes as soon as we complete the questionnaire development process.

To help keep everything private, your name will not be recorded on the interview notes or reported in any reports. The things you say may be put in a written summary of this interview. Your name will not be linked to any of your responses, though we may include quotes that you provide in our reports.

If you have questions about this research, please contact David Cantor, the Principal Investigator at (301-251-1500). If you have questions about your rights and welfare as a research participant, please call the Westat Human Subjects Protections office at 1-888-920-7631. Please leave a message with your first name, the name of the research study that you are calling about (CDC), and a phone number beginning with the area code. Someone will return your call as soon as possible.

A copy of this consent form will be provided to you for your records.

Please indicate your choices by checking the boxes below.

Do you agree to be interviewed? Yes No

Do you agree to be audio recorded? Yes No

Do you agree to be video recorded? Yes No

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Interviewer’s Signature Date