Consent - paper-based

Attachment 5: Paper-Based Informed Consent

Introduction

This is a research study about the experiences of households impacted by natural disasters. RTI International, a non‐profit research organization, is conducting this study for the United States Centers for Disease Control and Prevention (CDC).

What is the purpose of this study?

The study’s purpose is to learn in what ways natural disasters affect households and whether preparedness activities may help households get through disasters. Results of this study will increase the CDC’s ability to make recommendations about how households can remain self‐ sufficient during natural disasters.

Your household was selected to participate because you live in the geographic area impacted by the recent natural disaster that is highlighted in the cover letter.

What do you want me to do if I decide to be in this study?

Read and sign this consent form and then complete the survey. You must be 18 years old and living in the area during the recent natural disaster to participate. You can complete the survey in two ways:

1. Go online and complete a web survey

2. Complete the paper survey included in this packet and return it along with this signed consent form with pre‐paid envelope

Do I have to be in this study?

Participation is completely voluntary. You may decline altogether or leave blank any questions you do not wish to answer. The results of this research study may be published in a report that combines all participants’ data, but the information you provide will not be shared at an individual level, unless you permit. Should you share any potentially identifying data, such as your name or address, it will be deleted at the end of the research project.

How long will you need me?

If you agree to participate, it should take approximately 30 minutes to complete the paper survey or 15 minutes if you choose to participate in the web survey.

Are there any benefits or risks to me if I decide to be in this study?

There are no direct benefits or foreseeable risks of participating in this study. Your answers cannot be used to affect any disaster‐related benefits you might receive now or in the future, and your data will never be sold.

How many people will be in this study?

We plan to recruit approximately 1,000 people to be in this study.

Are there any incentives for being in this study?

We will give you incentives for being in the study. Included in this packet is a pre‐paid incentive of $2. You will receive an additional $10 if you complete the included paper survey or $20 if you complete the survey via the online web‐based instrument (instructions included in the cover letter).

Are there any additional costs to me for being in this study?

There should be no additional costs for you being in this study.

Will the information I give you be kept private?

This research is covered by a Certificate of Confidentiality from the Centers for Disease Control and Prevention. The researchers with this Certificate may not disclose or use information, documents, or biospecimens that may identify you in any federal, state, or local civil, criminal, administrative, legislative, or other action, suit, or proceeding, or be used as evidence, for example, if there is a court subpoena, unless you have consented for this use. Information, documents, or biospecimens protected by this Certificate cannot be disclosed to anyone else who is not connected with the research except, if there is a federal, state, or local law that requires disclosure (such as to report child abuse or communicable diseases but not for federal, state, or local civil, criminal, administrative, legislative, or other proceedings, see below); if you have consented to the disclosure, including for your medical treatment; or if it is used for other scientific research, as allowed by federal regulations protecting research subjects.

Will information be used for future studies?

No, any information we collect from you will only be used for this study. It will not be used for any future studies.

Who should I call if I have questions about this study or about my rights as a research volunteer? If you have any questions about this project, you can call Amy Helene Schnall, the principal investigator at the CDC at 1.770.488.3422. If you have questions about your rights as a research participant, please contact CDC’s Human Research Protection Office at 404.639.7570 or [email protected].

Thank you for your assistance in this important endeavor.

Signature

I would like to be given an incentive for my participation in this study. By signing this form, I agree to be in the study and receive the incentive.

Name of participant Signature of participant Date

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