Att D_ Informed Consent

Attachment D

Informed Consent Form

Consent to be in a Research Study Investigating the Implementation and Evaluation of Top-ranked HSMS Elements
	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 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 how you implement and evaluate the organization’s health and safety management system at your mine in an effort to learn the ideal HSMS processes for mine sites to utilize.
	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 HSMS processes have the biggest influence on workers’ health/safety behaviors.
	What will I do?	You will be asked to participate in an interview or focus group that will last no more than 60 minutes that discusses how you currently oversee and manage your HSMS.
	Where, when, for how long?	We will collect information in a room, on the surface, behind closed doors to protect your confidentiality. We will collect information at a time convenient for you and will take no more than 60 minutes of your time.
	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 participate in a focus group, there is a potential risk of a loss of confidentiality because you will be sharing your opinions with other members of this group. Although we are asking all participants in the group to keep information shared confidential, NIOSH cannot ensure this aspect of your confidentiality. Only NIOSH staff who are involved in collecting the information will have repeated access to your 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 that the industry utilizes their HSMS to reduce workplace incidents.
	Will my personal information be kept private?	We are not collecting your name. NIOSH is authorized to collect and keep your personal information and we will protect it to the extent allowed by law. There are conditions under the Privacy Act where release of your information is allowed. To learn more, 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 utilizes an HSMS to mitigate workplace works. 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 Gail McConnell, Human Research Protection Program, Acting Chair gmcconnell@cdc.gov, 412-386-4950.