Form 1462 Video Consent Slides

OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

Form 1462

Video Consent
Slides
Under the Paperwork Reduction Act, a federal agency may not conduct or sponsor, and a person is not required to
respond to collection of information subject to the requirements of the Paperwork Reduction Act unless that
collection of information displays a current valid OMB Control number. The OMB Control Number for this
information collection is XXXX-XXXX (expiration date: MM/DD/YYYY). The average amount of time to complete this
survey is 10 minutes. All responses to this collection of information are voluntary. If you have comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden send them to Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200
New Jersey Ave, S.E., Washington, DC, 20590.

NHTSA Form Number 1462

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1462

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1462

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1462

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1462

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1462

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1462

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1462

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1462

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1462

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1462

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

NHTSA Form Number 1462

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

Confidentiality
• The records of this research study will be kept completely
confidential.
• In any publication, we will not include any information that will make
it possible to identify you or your participation in the research study.
• Your de-identified research data and the documents that you signed
for this research study may, however, be reviewed and/or
photocopied by the University of Pittsburgh, or other persons /
agencies as required by law or allowed by federal regulation.

NHTSA Form Number 1462

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

Confidentiality
• Since you are being compensated for your participation in this study,
your name, address, and social security number will be released to
the Accounting Office. If the total reimbursement for your
participation in research is greater than $600 in a year, this will be
reported to the Internal Revenue Service (IRS) as income.
• Your Personally Identifiable Information (PII) will be kept secure and
separate from your research study data. Your identity will not be
linked to your research study data.
• Because we will de-identify your data, use a Participant ID to track
your research study data, and keep your data secure, there is a strong
defense against breach of confidentiality.
NHTSA Form Number 1462

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

Authorization
• If you wish to take part in this research study, you will be asked to confirm your
willingness to be involved at the end of this video.
• You will then be required to confirm your understanding of the consent by
selecting the “I ACCEPT” button underneath this video before you can continue.
• This allows the research study sponsor and investigators to collect, process, and
pass along de-identified research study data collected from you during the study
to other team members.
• Note that the file containing your name, telephone number, and email will be
kept separate from the research study data. No Personally Identifiable
Information (PII) will be shared. There is a strong defense against breach of
confidentiality.
• Also, of special note, your data will never be shared with your supervisor or
employer, and therefore not used for disciplinary action.
NHTSA Form Number 1462

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

Authorization
• As previously stated, your Personally Identifiable Information (PII) will be
kept in a secure file separate from your research study data. The research
study team will use your PII for purposes of maintaining contact and
communication with you during the study. Your PII will not be shared with
anyone not on the research study team. We will store your research study
data on secure computer servers maintained by the University of
Pittsburgh and the University of Pittsburgh Medical Center. These
databases may be audited or accessed by the following:

• [a] the study investigator and research staff of Dr. Daniel Patterson;
• [b] the study sponsor and/or its associated companies (i.e., the National Highway
Traffic Safety Administration in collaboration with the National Association of State
EMS Officials); and
• [c] regulatory or other governmental authorities of the United States, other persons
authorized by he study sponsor, the University of Pittsburgh, and other persons or
agencies as required or allowed by federal regulations.

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

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OMB Control Number: 2018XX-2127-XXX
Expiration Date: XX/XX/XXXX

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