Attachment 4 Sample Particpant Consent form

Sample Participant Consent Form

READING LEVEL 7.2 (ASSESSED BY FLESCH-KINCAID)

Introduction and Purpose:

You have been asked to take part in a survey as part of a research study. The purpose of the interview is to hear your opinions about [INSERT TOPIC]. e-Rewards and RTI International, a nonprofit research organization in North Carolina, are conducting the survey. The interview is sponsored by the Centers for Disease Control and Prevention (CDC).

Procedures:

The survey is about [INSERT TOPIC] and should take approximately [INSERT MINUTES] to complete.

Risk/Discomforts and Right to Refuse or Withdraw:

You might feel embarrassed or upset by some questions in this survey. You can decline to answer any questions for any reason. You can stop the survey at any time.

Benefits:

There is no direct benefit to you for being in this interview. However, you may learn more about [INSERT TOPIC].

Privacy:

Your responses will be kept private to the extent allowable by law. No identifying information will be included on the survey.

Payment:

We will give you [INSERT AMOUNT OR REWARDS POINTS] as a token of appreciation for completing the survey.

It is your choice to complete the survey. You can choose not to talk about any topic. You can stop taking the survey at any time.

Persons to Contact:

If you have questions about the interview, you can call Jennifer Uhrig at 1-800-334-8571, extension 3311. She can be reached between 9 a.m. and 5 p.m., Eastern Standard Time, Monday–Friday. If you have questions about your rights as a participant, you can call Wendy Visscher of RTI’s Office of Research Protection toll-free at 1-866-214-2043.

Consent:

Please choose one to continue with the survey:

I have read this consent form and agree to participate in the survey.

I have read this consent form and do not want to participate in the survey

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