App G_Invitational Email and Consent

Appendix G: Invitational Email and Consent

Form Approved

OMB No. 0920-XXXX

Expires

Date, 2014

Dear School District Employee:

The National Institute for Occupational Safety and Health (NIOSH) would like to invite you to participate in a health questionnaire survey. NIOSH is a federal public health agency and is a part of the Centers for Disease Control and Prevention (CDC). NIOSH was established to help insure safe and healthy working conditions for workers and to conduct research on worker safety and health. We will be conducting a study to better understand how associations between health outcomes and damp or moldy conditions can be used to prioritize remediation in schools. We selected 50 elementary schools within your district to be part of this study. As part of this, we will be offering an on-line health questionnaire to all employees who work in one of the 50 selected schools. We will also be testing classroom and other work spaces in a smaller number of schools for dampness, ventilation, and microbial agents.

To participate, we will ask you to complete an on-line health questionnaire. This should take 20 minutes or less. The questionnaire is on a CDC website. We will provide you with an identification number that gives you confidential access to the questionnaire. To go to the questionnaire, click on the CDC website: XXXXX XXXXX. Once you are on the website, you will enter your identification number to begin the questionnaire.

The following paragraphs contain information that will help you to decide whether you choose to participate.

Your participation is voluntary. You may choose to be in the study or not. You can choose to answer any or all of the questions. You may drop out any time, for any reason, without consequences to you.

NIOSH is authorized to collect your personal information and will protect it to the extent allowed by law. There are conditions under the Privacy Act where your information may be released to collaborators or contractors, health departments or disease registries, to the Departments of Justice or Labor, or to Congressional offices.

Any risks from completing this survey are minimal. The only risk we anticipate is the potential for loss of confidentiality. To minimize this risk all data is stored on a secure server at the Centers for Disease Control and Prevention, and only those authorized to work on this study will be able to see your results.

For questions about your rights, your privacy, or harm to you, contact the Director of Human Research Protections, Mark Toraason at mtoraason@cdc.gov, or 513-533-8591.

There are no direct benefits to you personally for participating in the study. However, what we learn may reduce health symptoms in school employees by providing proper approaches for responding to dampness in school buildings.

By completing the questionnaire, you give your consent to participate.

We hope that you will choose to participate in this important survey. If you have any questions, feel free to contact me at 304-285-5734. I will be happy to provide you with additional information about this study. Thank you for your time.

Sincerely,

Michelle Martin, MS

National Institute for Occupational Safety and Health

Centers for Disease Control and Prevention

1095 Willowdale Road, MS H2800

Morgantown, WV 26505

Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).