Mine Worker Recruitment Script/Consent

Attachment I

Informed Consent Form for Workers

Consent to be in a Research Study Improving Organizational Management and Worker Behavior through Worksite Communication Individual Worker Consent Form
	Who is conducting the study?	The National Institute for Occupational Safety and Health (NIOSH)/ the Office of Mine Safety and Health Research (OMSHR) is a non-regulatory federal agency that studies worker safety and health. We are part of the Centers for Disease Control and Prevention (CDC).
	What is the purpose of the study?	We want to learn, from your perspective, your perception of the organizations’ values and management of health and safety regarding communication about dust exposure and other risks on the job– and how these management practices influence your safety/health behaviors.
	Is participation voluntary?	Yes, the study is voluntary. You can choose to be in the study or not. You can choose to answer any or all questions. You can drop out any time for any reason without consequences to you. However, full participation will be helpful in informing what actions reduce your exposure to dust, helping to prevent the onset of dust-related disease.
	What will I do?	You will be asked to participate in the following over a six-week time period: • A pre-survey, wearing the Helmet-CAM, and completing an interview that also reviews the Helmet-CAM footage with you. This will take no more than two hours. • A mid-interview that includes wearing the Helmet-CAM and going over footage together. This will take no more than one hour. • A post-survey and interview that includes a final wearing of the Helmet-CAM. This will take no more than one hour and 15 minutes.
	Where, when, for how long?	We will collect information in a room, on the surface, behind closed doors to help keep your data secure. The time requested for each activity is listed in the above box.
	Are there any risks?	The questions in the study pose minimal risk to you, if you participate. We are not collecting your name. If you decide to share information learned from the Helmet-CAM with other individuals,NIOSH cannot ensure this aspect of your data security. Only NIOSH staff who are involved in collecting the information will have repeated access to your data and responses. In any public release of results, no data will be disclosed that could be used to identify specific individuals.
	What if I am injured or harmed?	On-site emergency treatment will be provided. 911 will be called if needed. Medical care or compensation will not be provided. If harmed through negligence of a NIOSH employee, you might obtain compensation under Federal Law.
	Will I be reimbursed or paid?	You will not be paid or reimbursed for participating because you will be participating during your normal work hours.
	Are there other benefits?	You will not directly benefit from the research but your answers could inform the ways to reduce exposure to silica dust and inform ways to mitigate other health/safety issues at the workplace.
	Will my personal information be kept private?	We are not collecting your name. To learn more about how we keep your data secure, contact the people listed below.
	Will I or anyone else receive study results?	Publications/reports/trainings will be produced based on the study results and contain suggested practices to improve the ways the mine site communicates about health and safety problems, including dust exposure. This will be available on the NIOSH website: http://www.cdc.gov/niosh/mining.
	Who can I talk to if I have questions?	For questions about the research study, contact Emily Haas, principal investigator, at EJHaas@cdc.gov or (412)386-4627. For questions about your rights, your privacy, or harm to you, contact Mark Toraason, Human Research Protection Program, mtoraason@cdc.gov, 513-533-8591.