Appendix B-C: Consent Form and Waiver

Appendix B: In-Home Informed Consent Form
INFORMED CONSENT
Consumer Product Safety Commission (CPSC) Survey
on Usage and Functionality of Smoke Detectors and
Carbon Monoxide Detectors in Households
Thank you for your interest in participating in the research study. This study is conducted by EurekaFacts on behalf
of the U.S. Consumer Product Safety Commission (CPSC). We are conducting a nationwide survey on household
fire and carbon monoxide (CO) safety. The purpose of this study is to gather information about the functionality of
smoke detectors and CO detectors in U.S. households by asking a series of survey questions and testing your
household smoke and CO alarms. Findings from this research will help CPSC improve home safety.
The combined survey and testing of smoke alarms and CO alarms will take up to 60 minutes. Our trained
and qualified two-member survey team will ask you questions related to your smoke detectors and CO detectors,
and then inspect these devices in your home. You will receive a $50 gift card from a major card company as a
token of appreciation for completion of the study.
If the survey team finds any detectors to be non-functioning, new detectors and/or batteries can be offered, free
of charge, based on availability. If you are renting your home, the property manager will need to be contacted to
arrange installation of the new detector at a later date. With your permission, we would like to collect nonfunctioning smoke or CO detectors and send them to CPSC’s lab to find out why they do not work. In
addition, we may request your permission to take a photograph of your smoke and CO detector(s) to study
different alarm types and functionalities.
Information collected from this study will help CPSC to improve household fire and CO safety. Your input will assist
with developing standards and guidelines that will help protect property and human life. This research does not
involve any foreseeable risks.
Your participation in this research study is completely voluntary. You may stop at any time if you do not want to
continue with the study by notifying a member of the survey team. Your responses will be maintained confidential
and will be used for research purposes only. At no time will any identifiable information be linked to any of your
answers. All information collected through our research process is reported to CPSC anonymously.
We ask for your consent to participate in answering questions as part of the survey portion of this study.
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I consent
I do not consent

We ask for your consent to participate in the smoke and CO alarm testing portion of this study in your home.
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I consent
I do not consent

Your signature below means that you have freely agreed to participate in this research study. You should consent
only if you have read this document and you understand its contents.

Print name

Signature

Date

Appendix C: Waiver, Release and Hold Harmless Agreement

Home Address:

____________________________________________________________

In consideration of the voluntary performance of my participation in the U.S. Consumer Product Safety
Commission (CPSC) Survey on Usage and Functionality of Smoke Detectors and Carbon Monoxide
Detectors in Households, which is being conducted at my residence, located at
______________________ I, on behalf of myself, and all members of family, as well as
my heirs, executors, administrators or successors, hereby waive any claim or cause of action of any nature
that I have, or in the future may have, against any and all individual or organizational participants in the
CPSC Survey on Usage and Functionality of Smoke Detectors and Carbon Monoxide Detectors in
Households, including but not limited to CPSC and EurekaFacts, LLC, its agents or employees, which
claim or cause of action grows out of or results from increased levels of carbon monoxide, a fire or other
damage, following the testing and inspection of one or more of the smoke and or carbon monoxide
detectors, in addition one or more of the following action(s):
1.
3.
5.
7.

Replaced batteries
Provided new smoke detector(s)
Collected faulty smoke detector(s)
Obtained photograph of smoke/ carbon
monoxide detector(s) (Device only)

2. Provided new CO detector(s)
4. Collected faulty CO detector(s)
6. Took no additional action

I further hereby agree to release and hold harmless any and all organizational and individual participants
including the [Partner Name] and municipality of [MUNICIPALITY NAME] in the CPSC Survey on
Usage and Functionality of Smoke Detectors and Carbon Monoxide Detectors in Households from and
against all damages of any kind, to persons or property, growing out of or resulting from a fire or
increased levels of carbon monoxide in my referenced home.
I acknowledge having read, understood, and agreed to the above waiver, and release.
Print name

Signature

Date

Witness (Print name)

Signature

Date

*This form generally indicates that the occupant or owner of the property agrees to waive his or her rights to sue any individual, any
municipality and any other organizations or individuals involved in the safety inspection of this home, if a fire or increased levels of
carbon monoxide occurs after the inspection. The purpose of the waiver is to protect the individual or any of the organizations involved
against liability arising from the home fire inspection. This statement is intended for information only, the terms of the waiver
themselves shall prevail if there are any questions. You should seek advice if you do not understand this waiver.