Form 1774 Emory CIREN Consent for vehicle inspection

STUDY00005031
IRB Approved
9/27/2022

CONSENT FOR VEHICLE INSPECTION
Emory/Grady Crash Injury Research and Engineering Network (CIREN)
Why are you being asked to sign this form? The CIREN team at Emory and Grady is
investigating your crash as part of an effort to collect data on crashes and the injuries that occur
from them for the US Department of Transportation, National Highway Traffic Safety
Administration (NHTSA). You are being asked for your permission to inspect your vehicle.
What does a vehicle inspection involve? A trained crash investigator will photograph and
perform measurements on the outside and inside of your vehicle that was involved in the crash.
The investigator will also attempt to download the contents of the event data recorder in your
vehicle.
What will be done with the data that are collected from my vehicle? The data from your
vehicle will have any information that could identify you removed and will be uploaded to a
NHTSA database. These data will be used in analyses to improve vehicle safety and improve the
treatment of injuries caused by crashes.
Can you change your mind about consenting to a vehicle inspection? You can change your
mind about providing consent for a vehicle inspection at any time by completing the revocation
form that was provided in this packet; however, data that have already been uploaded to the
NHTSA database cannot be removed.
By signing below, I grant the Emory/Grady CIREN team permission to access and inspect my
vehicle.
________________________________________________________________________
Signature of Subject
Date
Time

________________________________________________________________________
Signature of Legally Authorized Representative
Date
Time
(if applicable)

Version Date: 09/02/2022