Attachment I
Consent Documents
NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH (NIOSH)
CENTERS FOR DISEASE CONTROL
U.S. PUBLIC HEALTH SERVICE
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
AGREEMENT TO PARTICIPATE IN A RESEARCH STUDY
Home Care Worker Version
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You have been asked to participate in a NIOSH research study. We explain here the nature of your participation, describe your rights, and specify how NIOSH will treat your records.
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I. DESCRIPTION
1. Title:
Evaluation of a homecare worker educational program
2. Sponsor and/or Project Director:
The National Institute for Occupational Safety and Health (NIOSH), Sherry Baron (Project Officer)
Purpose of Research:
NIOSH has been working with your union, with the Alameda County Public Authority for In-Home Supportive Services and the University of California to develop a training program and safety handbook for homecare workers in Alameda County. This project is aimed at improving safety for home care workers and for their consumers.
Benefits of Research:
For your participation in this study you will be receiving a copy of the home care workers handbook and will be participating in a training program. There are no other direct benefits to you from taking part in this study.
II. CONDITIONS OF THE STUDY
Procedures that we will use:
We will conduct an interview with you now that will last about 30 minutes. An interviewer will read you each survey question over the telephone and will then type your answer into the computer. In about two months we will conduct another telephone interview that will also last about 30 minutes. You will also be participating in a training program where you will receive the new Home care workers Safety Handbook and be taught how to use it. The training program will take place in Alameda County and will last about an hour. You will have a choice a couple of different weekday or weekend times for the training. The surveys will ask you questions about your work as a home care worker, about your safety and about any injuries you may have had working as a home care worker. If you do not want to answer a question, just say so, and we will move on to the next one. You may also stop the interview at any time.
For your participation in the whole program you will receive $80 in the form of grocery gift cards. You will receive $20 at the completion of this survey and the remainder once you have completed the second survey and the training program. This is to reimburse you for the time you spent in taking part in this study.
2. Risks Associated with Participation:
The surveys will ask you questions about your work as a home care worker, your feeling about your safety working as a home care workers, and about injuries you may have had working as a home care worker. Some of the questions might make you feel uncomfortable and if you do not want to answer a question, just say so, and the interviewer will move on to the next one. You may also stop the interview at any time.
3. Injury or harm from this project is unlikely. But if it results, medical care is not provided, other than emergency treatment. If you are injured through negligence of a NIOSH employee you may be able to obtain compensation under Federal Law. If you want to file a claim against the Federal government your contact point is: Public Health Service Claims Office: (301) 443-1904. If you are injured or harmed through the negligence of a NIOSH contractor, your claim would be against the contractor, not the federal government. If an injury or harm should occur to you as the result of your participation, you also should contact: Sherry Baron, 513 458-7159 or Cheryl F. Estill, Chair NIOSH HSRB, 513-533-8591.
4. If you have questions about this research, contact Sherry Baron, 513- 458-7159. If you have questions about your rights as a member of this study, contact Cheryl F. Estill, Chair NIOSH Human Subjects Review Board, 513-533-8591
5. Your participation is voluntary and you may withdraw your consent and your participation in this study at any time without penalty or loss of benefits to which you are otherwise entitled.
III. USE OF INFORMATION
This study is being done by The National Institute for Occupational Safety and Health (NIOSH). NIOSH is part of the Centers for Disease Control (CDC), a government agency in the Department of Health and Human Services. We collect this information in order to learn about various kinds of work hazards that may influence the health of the American worker and to help us develop better training materials.
NIOSH is allowed to collect and keep information about you, including your results from this study, because of three laws passed by Congress. These laws are:
The Public Health Service Act (42 U.S.C 241)
The Occupational Safety and Health Act (29 U.S.C. 669)
The Federal Mine Safety and Health Act of 1977 (30 U.S.C. 951)
We will be asking for your name, address and telephone number. This information will only be used to contact you for the interviews and to remind you about the training. Once the surveys and training are complete this identifying information will be destroyed so that your survey responses will be completely anonymous. All of the answers you give to the questions will be stored in a locked file cabinet, accessible only to project staff. All records we have that contain written information that could identify you will be destroyed at the end of the study, which is currently June 2011.
You will decide whether you want to provide us with this information by being in this study. You are free to choose not to be in this study. It is up to you. You should know, however, that there are conditions under the Privacy Act when we could be authorized to release this information to outside sources. These conditions under which we might release this information are listed on the back of this form.
SIGNATURES
I have read this consent form and received a copy of the conditions for data release under the Privacy Act (Appendix A). I agree to participate in this study.
PARTICIPANT Age (signature)
I, the NIOSH representative, have accurately described this study to the participant.
REPRESENTATIVE Date ____________
(signature)
Appendix A
The Information you provide will become part of the CDC Privacy Act System, 09-20-0147, “Occupational Health Epidemiological Studies and EEOICPA Program Records” and may be disclosed to
Appropriate state or local heath departments to report communicable diseases;
A State Cancer Registry to report cases of cancer where the state has a legal reporting program providing for confidentiality;
Private contractors assisting NIOSH;
Collaborating researchers under certain circumstances to conduct further investigations;
One or more potential sources of vital statistics to make determinations of death, health status or to find last known address;
The Department of Justice or the Department of Labor in the event of litigation;
Congressional offices assisting an individual in locating his or her records;
The Department of Justice to assist in determining the eligibility for compensation to uranium workers or their survivors [optional but must be used if study pertains to uranium workers]
You may request an accounting of the disclosures made by NIOSH.
Except for these and other permissible disclosures authorized by the Privacy Act, or in limited circumstances required by the Freedom of Information Act, no other disclosures may be made without your written consent.
Oral consent for home care workers
Introduction and Purpose
My name is ____________. I work for NAME OF CONTRACTOR and we are working on a research study with the National Institute for Occupational Safety and Health (NIOSH) which is part of the Center for Disease Control and Prevention. NIOSH has been working with your union, with the Alameda County Public Authority for In-Home Supportive Services and the University of California to develop a training program and safety handbook for homecare workers in Alameda County. I would like to invite you to take part in this project, which is aimed at improving safety in the homecare setting. We hope that the project will help improve the safety of homecare workers and consumers. Your participation will help us improve these education materials before we make them available to other workers and consumers.
Procedures
If you agree to participate in this project, I will conduct an interview with you now that will last about 30 minutes. In about two months I will conduct another telephone interview that will also last about 30 minutes. You will also be participating in a training program where you will receive the new Home care workers Safety Handbook and be taught how to use it. The training program will take place in Alameda County and will last about an hour. You will have a choice a couple of different weekday or weekend times for the training. The surveys will ask you questions about your work as a home care worker, your feeling about your safety working as a home care workers, and about injuries you may have had working as a home care worker. If you do not want to answer a question, just say so, and I will move on to the next one. You may also stop the interview at any time.
For your participation in the whole program you will receive $80 in the form of grocery gift cards. You will receive $20 at the completion of this survey and the remainder once you have completed the second survey and the training program. This is to reimburse for the time you spent in taking part in this study.
Benefits
For your participation in this study you will be receiving a copy of the home care workers handbook and will be participating in a training program. There are no other direct benefit to you from taking part in this study.
Risks/Discomforts
As with all research, there is a chance that confidentiality could be compromised; however, we are taking precautions to minimize this risk. You are free to decline to answer any questions you don't wish to, or to stop the interview at any time.
Confidentiality
Your study data will be handled as confidentially as possible. We will store the information from the survey in a locked cabinet located in the offices of NIOSH. We will not use your name or other identifying information in any reports or publications of our discussion.
When the research project is completed, we will save the survey data for use in future research. We will retain these records for up to 5 years after the project is over.
Rights
Participation in research is completely voluntary. You are free to decline to take part in the project. You can decline to answer any questions and are free to stop taking part in the project at any time. Whether or not you choose to participate in the research and whether or not you choose to answer a question or continue participating in the project, there will be no penalty to you or loss of benefits to which you are otherwise entitled. If you decide not to do it, it will not affect your job situation or your participation in the in home supportive services program.
Questions
If you have any questions about this project, you may call Sherry Baron from NIOSH at 513-458-7159.
If you have any questions about your rights or treatment as a research participant in this study, please contact the
Do you have any questions for me?
************************************************************
Consent
If you agree to participate, please say so. You will be given a copy of this form to keep for your own records.
NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH (NIOSH)
CENTERS FOR DISEASE CONTROL
U.S. PUBLIC HEALTH SERVICE
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
AGREEMENT TO PARTICIPATE IN A RESEARCH STUDY
Client version
‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑--------‑-------------
You have been asked to participate in a NIOSH research study. We explain here the nature of your participation, describe your rights, and specify how NIOSH will treat your records.
‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑---------------------
I. DESCRIPTION
Title:
Evaluation of a homecare worker educational program
Sponsor and/or Project Director:
The National Institute for Occupational Safety and Health (NIOSH), Sherry Baron (Project Officer)
Purpose of Research:
NIOSH has been working with the Alameda County Public Authority for In-Home Supportive Services, the home care workers labor union, and the University of California to develop a training program and safety handbook for homecare workers in Alameda County. This project is aimed at improving safety for home care workers and for their consumers.
Benefits of Research:
There are no direct benefits to you from participating in this study.
II. CONDITIONS OF THE STUDY
Procedures that we will use:
We will conduct an interview with you now that will last about 15 minutes. An interviewer will read you each survey question over the telephone and will then type your answer into the computer. In about two months we will conduct another telephone interview that will also last about 15 minutes. The surveys will ask you questions about yourself, your home care worker and your safety. If you do not want to answer a question, just say so, and we will move on to the next one. You may also stop the interview at any time.
For your participation in the whole program you will receive $35 in the form of grocery gift cards. You will receive $10 at the completion of this survey and the remainder once you have completed the second survey. This is to reimburse you for the time you spent in taking part in this study.
Risks Associated with Participation:
The surveys will ask you questions about yourself and about you home care worker. Some of the questions might make you feel uncomfortable and if you do not want to answer a question, just say so, and the interviewer will move on to the next one. You may also stop the interview at any time.
Injury or harm from this project is unlikely. But if it results, medical care is not provided, other than emergency treatment. If you are injured through negligence of a NIOSH employee you may be able to obtain compensation under Federal Law. If you want to file a claim against the Federal government your contact point is: Public Health Service Claims Office: (301) 443-1904. If you are injured or harmed through the negligence of a NIOSH contractor, your claim would be against the contractor, not the federal government. If an injury or harm should occur to you as the result of your participation, you also should contact: Sherry Baron, 513-458-7159 or Cheryl F. Estill, Chair NIOSH HSRB, 513-533-8591.
If you have questions about this research, contact Sherry Baron, 513- 458-7159. If you have questions about your rights as a member of this study, contact Cheryl F. Estill, Chair NIOSH Human Subjects Review Board, 513-533-8591
Your participation is voluntary and you may withdraw your consent and your participation in this study at any time without penalty or loss of benefits to which you are otherwise entitled.
III. USE OF INFORMATION
This study is being done by The National Institute for Occupational Safety and Health (NIOSH). NIOSH is part of the Centers for Disease Control (CDC), a government agency in the Department of Health and Human Services. We collect this information in order to learn about various kinds of work hazards that may influence the health of the American worker and to help us develop better training materials.
NIOSH is allowed to collect and keep information about you, including your results from this study, because of three laws passed by Congress. These laws are:
The Public Health Service Act (42 U.S.C 241)
The Occupational Safety and Health Act (29 U.S.C. 669)
The Federal Mine Safety and Health Act of 1977 (30 U.S.C. 951)
We will be asking for your name, address and telephone number. This information will only be used to contact you for the interviews. Once the interviews are complete this identifying information will be destroyed so that your survey responses will be completely anonymous. All of the answers you give to the questions will be stored in a locked file cabinet, accessible only to project staff. All records we have that contain written information that could identify you will be destroyed at the end of the study, which is currently June 2011.
You will decide whether you want to provide us with this information by being in this study. You are free to choose not to be in this study. It is up to you. You should know, however, that there are conditions under the Privacy Act when we could be authorized to release this information to outside sources. These conditions under which we might release this information are listed on the back of this form.
Appendix A
The Information you provide will become part of the CDC Privacy Act System, 09-20-0147, “Occupational Health Epidemiological Studies and EEOICPA Program Records” and may be disclosed to
Appropriate state or local heath departments to report communicable diseases;
A State Cancer Registry to report cases of cancer where the state has a legal reporting program providing for confidentiality;
Private contractors assisting NIOSH;
Collaborating researchers under certain circumstances to conduct further investigations;
One or more potential sources of vital statistics to make determinations of death, health status or to find last known address;
The Department of Justice or the Department of Labor in the event of litigation;
Congressional offices assisting an individual in locating his or her records;
The Department of Justice to assist in determining the eligibility for compensation to uranium workers or their survivors [optional but must be used if study pertains to uranium workers]
You may request an accounting of the disclosures made by NIOSH.
Except for these and other permissible disclosures authorized by the Privacy Act, or in limited circumstances required by the Freedom of Information Act, no other disclosures may be made without your written consent.
Text of verbal consent for clients
Introduction and Purpose
My name is ____________. I work for NAME OF CONTRACTOR and we are working with the National Institute for Occupational Safety and Health (NIOSH) which is part of the Center for Disease Control and Prevention. NIOSH has been working with the Alameda County Public Authority for In-Home Supportive Services, with the home care workers union and with the University of California to develop a training program and safety handbook for homecare workers in Alameda County. I would like to invite you to take part in this project, which is aimed at improving safety for home care workers and their consumers. We hope that the project will help improve the safety of homecare workers and consumers. Your participation will help us improve these education materials before we make them available to other workers and consumers.
Procedures
If you agree to participate in this project, I will conduct an interview with you now that will last about 15 minutes. In about two months I will conduct another telephone interview that will also last about 15 minutes. The surveys will ask you questions about yourself, your safety and about your home care worker. If you do not want to answer a question, just say so, and I will move on to the next one. You may also stop the interview at any time.
For your participation in the whole program you will receive $35 in the form of grocery gift cards. You will receive $10 at the completion of this survey and the remainder once you have completed the second survey. This is to reimburse you for the time you spent in taking part in this study.
Benefits
Your home care worker will be participating in a free safety training program and will receive the home care worker safety handbook. There are no direct benefits to you from taking part in this study.
Risks/Discomforts
As with all research, there is a chance that confidentiality could be compromised; however, we are taking precautions to minimize this risk. You are free to decline to answer any questions you don't wish to, or to stop the interview at any time.
Confidentiality
Your study data will be handled as confidentially as possible. We will store the information from the survey in a locked cabinet located in the offices of NIOSH. We will not use your name or other identifying information in any reports or publications of our discussion.
When the research project is completed, we will save the survey data for use in future research. We will retain these records for up to 5 years after the project is over.
Rights
Participation in research is completely voluntary. You are free to decline to take part in the project. You can decline to answer any questions and are free to stop taking part in the project at any time. Whether or not you choose to participate in the research and whether or not you choose to answer a question or continue participating in the project, there will be no penalty to you or loss of benefits to which you are otherwise entitled. If you decide not to do it, it will not affect your participation in the in home supportive services program.
Questions
If you have any questions about this project, you may call Sherry Baron from NIOSH at 513-458-7159.
If you have any questions about your rights or treatment as a research participant in this study, please contact Cheryl F. Estill, Chair NIOSH Human Subjects Review Board, 513-533-8591
Do you have any questions for me?
************************************************************
Consent
If you agree to participate, please say so. You will be given a copy of this form to keep for your own records.
| File Type | application/msword |
| Author | slb8 |
| Last Modified By | Thelma Elaine Sims |
| File Modified | 2010-10-14 |
| File Created | 2010-10-14 |