Form Approved
OMB No. 0920-0792
Exp. Date 08/31/2021
Attachment 2- EHS-Net KMC Study Worker Recruiting Screener and Informed Consent
Public reporting burden for this collection of information is
estimated to average 2 minutes per response, including
the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB
control number. Send comments regarding this burden estimate or any
other aspect of this collection of information, including
suggestions for reducing this burden, to: CDC/ATSDR Information
Collection Review Office, MS D-74; 1600 Clifton Road NE, Atlanta,
Ga. 30333; ATTN: PRA (0920-0792)
Let me give you a little background on why I’m here. I’m working with __________________ (health department) on a research project. Your restaurant was picked at random to be in this project, and your manager said that it would be okay for you to talk to me for a few minutes. However, your participation is voluntary—you don’t have to talk to me if you don’t want to- I won’t tell your manager. If you do talk with me, I won’t tell your manager anything that you say.
Would you be willing to talk to me for about 10 minutes about your work behavior and this restaurant’s policies and practices?
No Okay, thanks for your time. (End interview)
Yes Great, thanks.
I’m going to ask you some questions, and if any of the questions make you uncomfortable you can choose not to answer them. The information we collect today will be combined with information from other restaurants in various states. Your name and your restaurant’s name will not be linked in any way to the information we collect, nor will they be included in any reports.
The information you provide will be valuable in helping us understand the food safety knowledge level and attitudes of food workers, we ask you to be as open and honest as possible.
Do you have any questions?
If you have any questions at a later time, you can contact: (Local Contact Name). (If have card) My information is on this card.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Hello this is __________ with the _________ Health Department |
| Author | lrg |
| File Modified | 0000-00-00 |
| File Created | 2021-08-17 |