Appendix I.a - Consent Form Study 1

Questionnaire Consent Form

Eastern Virginia Medical School (EVMS) Institutional Review Board

Study Title:	Effectiveness of Child Passenger Safety Messages (Study 1)
Name of Investigators:	Lawrence Decina, M.S.; Kelli England Will, Ph.D.
Sponsor:	National Highway Traffic Safety Administration

You are being asked to participate in a research study involving the collection of information in the form of questionnaire. The purpose of the research project is to get parent perceptions of child safety seat information. Approximately 300 people are expected to take part in this study at two sites in the United States.

You will be asked to take a survey, view some child safety seat information, and answer another survey. You will be “randomized” into one of five study groups to view one of five different versions of child safety seat information. This means that you will be assigned into a group by chance. It is like throwing dice. A computer program will do this, so neither you nor the investigator will choose what group you will be in. You will have a 1 in 5 chance of being placed in any group. Completion of this research will require approximately 60-75 minutes of your time.

Upon completion of the study today, you will receive a $50 gift card. There are no additional costs to you associated with taking part in this study.

You will be responding in a secure questionnaire environment on a computer. We will not be collecting your name or other identifying information about you in connection with this study. The data collected from all participants will be anonymous. Your answers in the database will not be associated with your name or otherwise linkable to you. The database will be maintained by password-only access, and only study staff will have access to the database.

Although the results of this research may not benefit you directly, they may be made available upon request.

Study records may be reviewed and/or copied in order to meet state and/or federal regulations. The study sponsor also will have access to all study records, including data collected. Other reviewers may include, for example, the Eastern Virginia Medical School Institutional Review Board. Information learned from this research may be used in reports, presentations and publications. Neither the study records nor reports, presentations or publications will personally identify you.

Taking part in this study is your choice. If you decide not to take part, your choice will not affect any medical or educational benefits to which you are entitled. You may choose to leave the study at any time.

If you have any questions pertaining to this research, you may contact the investigators, Dr. Kelli Will at (757) 668-6449, or Lawrence E. Decina at (215) 538-3820. You may also contact Dr. Robert Williams, an employee of Eastern Virginia Medical School, at (757) 446-8423. If you have any questions pertaining to your rights as a research subject, you may contact a member of the Institutional Review Board through the Institutional Review Board office at (757) 446-8423.

Consent to Participate

You may choose to print a copy of this form. You may also request information from the investigator before continuing. By clicking “Yes, I agree to participate,” you agree to take part in this study and accept the risks.

• YES, I AGREE TO PARTICIPATE (Continue on to Questionnaire)

• NO, I DECLINE TO PARTICIPATE (Exit the System)

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