Consent Form

Appendix F. Informed Consent

Consent to be in a Research Study Local/Short-Haul Truck Drivers Health & Safety Survey
	Who is conducting the study?	NIOSH is a federal agency that studies worker safety and health. We are part of the Centers for Disease Control and Prevention (CDC).
	What is the purpose?	The purpose of this research is to learn more about how work in the local/short-haul industry relates to truck driver health & safety.
	What will I do?	You will complete a paper and pen hard copy survey. We will ask you about your work, your health, and organizational policies.
	When, where, for how long will I be needed?	You will complete the survey here on location and the whole process will last about 30 minutes.
	Are there any risks?	There is very little risk to you if you take part in this survey. However, if you tell us that you are in imminent danger at your worksite (i.e. that you are at risk of serious physical harm or death), we will need to report this to your employer. If we actually observe an imminent danger, we will need to report this to your employer and OSHA. Please see Human Subject Research: Acknowledgement of Risk Information below.
	Is my participation voluntary?	The study is voluntary. You may choose to be in the study or not. You may choose to answer any or all questions. You may drop out any time for any reason without consequence to you.
	What if I’m injured or harmed?	On-site emergency treatment will be provided. 911 will be called if needed. Medical care or compensation will not be provided. If harmed through negligence of a NIOSH employee, you might obtain compensation under Federal Law. If a NIOSH contractor is negligent, you can file a claim with that contractor.
	Will I be reimbursed or paid?	You will receive a token of appreciation for completing the survey. The amount will be $10.
	Are there other benefits?	Currently, very little is known about work design and well-being in local/short haul driving. Your honest answers may increase knowledge about the health and safety issues facing all local/short-haul truck drivers.
	Will my personal information be kept private?	NIOSH is authorized to collect your personal information and will protect it to the extent allowed by law. This survey is anonymous. We are not collecting any personal identifying information. Reporting of results will be in summary presentation only.
	Will I or anyone else receive study results?	At the conclusion of the study, the summary results for the entire study will be used to communicate the research study findings to the employers involved, the L/SH industry at large, and the scientific community.
	Who can I talk to if I have more questions?	For questions about the research study, contact the principal investigator, Jeannie Nigam at [email protected] or (513) 533-8284 or Aimee Dyal, survey facilitator, at [email protected] or (706) 540-3711. 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 phone 513-533-8591. Research at Kennesaw State University that involves human participants is carried out under the oversight of an Institutional Review Board. Questions or problems regarding these activities should be addressed to the Institutional Review Board, Kennesaw State University, 585 Cobb Avenue, KH3403, Kennesaw, GA 30144-5591, (470) 578-2268.

COVID-19 Human Subject Research: Acknowledgement of Risk Information

I am aware that participation in research described in the consent form may include activities that may cause exposure to COVID-19. Although Kennesaw State University has taken reasonable steps to provide me with appropriate information and protections in order to participate in a research study, I understand participation in this activity is not without risk.

I understand that this study cannot be successfully completed without certain inherent risks of COVID-19 exposure. I have carefully read, clearly understand, and accept this notice of risk.

I agree to be notified if COVID-19 disease exposure is identified in research staff during the next 2-week time period (after which my contact information will be destroyed per the confidentiality requirements laid out in the Consent Form).

Further, I agree to contact the research personnel (at the contact information provided to me) in the event that I should be diagnosed with COVID-19 in the next 2-week time period.