consent form

OMB No. 0990-0421

Attachment B

Consent to Participate in the U.S. Department of Health and Human Services (HHS), Office of the Assistant Secretary for Planning and Evaluation (ASPE) Climate Change Indicators and Adaptation Planning Webinar

Introduction

The Lewin Group and the U.S. Department of Health and Human Services (HHS), Office of the Assistant Secretary for Planning and Evaluation (ASPE) invite you to participate in a webinar. This webinar will be hosted and moderated by The Lewin Group, a national health and human service consulting firm.

HHS/ASPE wishes to identify and evaluate the data sources employed when health indicators are used in climate change planning (including the integrity of the data sources and any barriers to accessing these data), thereby enabling the Department to better understand the needs of local and state health departments in the planning and evaluation of their climate change adaptation planning.

How long will you need me? What do you want me to do if I decide to be in this webinar?

Candidates will be asked to participate in a webinar. The webinar will be conducted through teleconference or videoconference, or via WebEx. The webinar will include questions which ask about climate change in your jurisdiction, climate change health indicators, and climate change adaptation planning. The webinar should take no more than two hours to complete.

Are there any risks to me if I decide to be in this study?

There are no recognized risks as participants will be asked about standard job duties and responsibilities.

Are there any benefits from being in this study?

The positive aspects of participating in this study include contributing to the information provided to policymakers, researchers, and the general public about effective climate change adaptation planning activities and guidance for future improvements in the area.

Will the information I give you be kept private?

Notes will be taken during the webinars and a paper summarizing the results will be provided to HHS/ASPE. The webinar may also be recorded with permission of all participants.

Who should I contact if I have questions about this study?

HHS/ASPE –Renee.Dickman@hhs.gov

Do I have to be in this study?

Participation in this study is voluntary and you may choose not to answer any question or stop at any time. Please ask questions if there is anything you do not understand.

Signature

I have been told about the webinar. I have been allowed to ask questions. I had all of my questions answered. I would like to be in the webinar. By signing this form, I agree to be in the webinar.

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Signature of participant Date

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0421. The time required to complete this information collection is estimated to average 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer