Consent Form

Information and Communications Technology Needs Assessment Survey

Informed Consent Form

This form will be the first page of the online survey and also be the cover page to the print version.
Final version of this form will be vetted and approved by the labor unions and FRA

Purpose:

The attached questionnaire is part of a survey being conducted by the US Department of Transportation Volpe Center on behalf of the Federal Railroad Administration Office of Research, Development and Technology (FRA RD&T).

The purpose of the survey is to learn more about Information and Communications Technology (ICT), which relates to the technology and tools that railroaders, like you, use to share, distribute, gather and communicate information. Our goal is to understand how best to communicate important safety information to you and the railroad industry, generally, and specifically as part of the FRA RD&T Railroaders’ Guide to Healthy Sleep website. Participation means only completing the attached questionnaire.

Research Procedures:
Should you agree to participate, the questionnaire should take you 15–20 minutes to complete, whether online or on paper. If you have already taken this survey previously, we ask that you decline to participate a second time.

Benefits and Potential Risks:
There is no expected benefit to you as a result of completing this survey. However, your participation will help the FRA RD&T to better understand railroader ICT use and preferences, in order to improve the Railroaders’ Guide to Healthy Sleep website and best reach and communicate with railroaders, like you.

The potential risks of participating in this survey are less than those ordinarily encountered in daily life or during the performance of routine work. There is a slight risk that your responses may cause you to change your ICT behaviors.

Confidentiality:
A unique ID number has been assigned to you. The ID number will allow each questionnaire to be tracked so that only non-respondents will receive reminders. The list of participants and corresponding ID numbers will be kept in a secure location, separate from responses.

No identifiable information is being requested of you or otherwise collected. All online and paper responses will be kept confidential. Electronic and paper responses will be maintained in a secure location. In any study reporting, only grouped summary information would be presented. No data would identify any individual.

Rights:
Taking this survey is completely voluntary. You have the right to decline to participate, or to discontinue your participation at any point without penalty. You have the right to refuse to answer any question(s) for any reason.

Questions:
If you have any questions or would like additional information about this survey, please contact the project director, Dr. Heidi Howarth, at heidi.howarth@dot.gov or 617-494-2522. The Office of Management and Budget has approved this project. You may also contact OMB at (202) ____-______ with any questions.

If you are completing this questionnaire on paper, please sign below and return this sheet with the questionnaire. If you are completing it online, please fill in the appropriate circle below the question:

“I understand the above information. I voluntarily consent to participate in the survey.”

________________ ______________

Signature Date

(Fill in the circle that applies)  Yes  No

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ICT Survey Consent Form DRAFT, 10/26/2018