Consent Form

Informed Consent Form
PRIVACY ACT STATEMENT
In accordance with the Privacy Act of 1974 (Public Law 93-579), this notice informs you of
the purpose of the survey and how the findings will be used. Please read it carefully.
AUTHORITY: 10 U.S.C. 503, 2358
PRINCIPAL PURPOSE: Information collected in this survey will be used to learn about
behaviors related to infant sleep product warning labels. This information will be used to
assist the Consumer Product Safety Commission (CPSC) in developing strategies and best
practice approaches for delivering warnings to caregivers of infants.
ROUTINE USES: None.
DISCLOSURE: Providing information on this survey is voluntary. There is no penalty if you
choose not to respond. However, your maximum participation is encouraged so that the data
collected will be complete and representative. Your survey instrument will be treated as
confidential. Personally identifiable information (PII) will be used only by persons engaged in,
and for the purposes of, the survey. Only group statistics will be reported.
Value
1
2
98

Value Label
I wish to continue
I do not wish to continue
Refused

If 2 or 98, respondent was an INELIGIBLE respondent.
If 1, proceed to next page.
We are inviting you to take part in a research study. This will involve completing a web-based
survey. It should take you about 15 minutes to complete.
There are neither risks nor benefits to you for taking part in this survey. Any money you
receive is a small token to thank you for taking part, if you choose to do so.
Your participation is voluntary. This means that you are free to choose not to take part, or to
skip certain questions. There is no penalty if you choose not to respond. However, your
complete participation will help with future educational efforts. It is important that as many
people respond to this survey as possible so that the information we receive is complete.
Your personal information will be kept separate from your survey responses. Government
personnel will not have access to your name, address, or email address; they will only have
access to your responses. Government personnel will not be able to trace your responses
back to you. Answers will be reported only for the whole group. If you have any questions
about this survey at any time, please contact the survey administrator by emailing
[email protected].

Thank you for considering participation in this survey.