Mine Worker Oral Consent Script

Attachment F

Mine Worker Survey Oral Consent Script

Form Approved
OMB No. 0920-15BM
Exp. Date xx/xx/2016

First, thank you very much for your time. We conduct research for the National Institute for Occupational Safety and Health (NIOSH) Office of Mine Safety and Health Research (OMSHR). We collect information in order to learn about various kinds of work hazards that may affect the health and safety of the mine worker. In this current study we are recruiting mine workers to answer questions about what you think has the biggest impact on your personal health and safety behaviors so we can try to improve the organizational emphasis and support for workers’ health and safety.

This study involves filling out a short survey questionnaire. Your participation is completely voluntary. If you choose to participate, it should take about 15 minutes to complete. Please do not write your name on this questionnaire so you will not be linked to your responses. Information collected from you will be kept private and no individual data will be reported from this study – only results reported by groups.

Questions are not of a sensitive nature and you may chose not to answer any or all of them. Only NIOSH staff that collect and prepare the data for analysis will have access to your answers. There are no individual benefits to participation. You have the right to discontinue your participation without penalty at any time.

If you stay and complete the paper-pencil survey this is an indication that you consent to participating in this portion of the study. If you would like one of us to read the survey for you, please call one of us over and we can record your responses for you. If you would like to complete the survey electronically, call one of us over and we will provide you with a survey link.

We also have contact information available if you have follow-up questions:

If you have any comment about the tests/procedures, you should contact Emily Haas, Principal Investigator, ejhaas@cdc.gov, 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.

Public reporting burden of this collection of information is estimated to average 5 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).