Pre-Interview Consent Letter

P RE-INTERVIEW LETTER FOR POTENTIAL SUBJECTS

U.S. CONSUMER PRODUCT SAFETY COMMISSION

4330 EAST-WEST HIGHWAY

BETHESDA, MD 20814

date

Project number: «Tkno»

«Title» «FirstName» «LastName»

«Address1»

«City», «State» «PostalCode»

Dear «Title» «LastName»:

Because of your recent medical history, we are asking you to take part in a study about injuries and exposures to fire fighters. The goal is to prevent occupational fire fighter injuries and exposures in the future. This study is being conducted by the National Institute for Occupational Safety and Health (NIOSH), a federal agency that studies worker safety and health. NIOSH is part of the Centers for Disease Control and Prevention (CDC).

All work-related visits seen in the Emergency Department at «HospName» are reported to the U.S. Consumer Product Safety Commission (CPSC). CPSC shares these data with NIOSH. These data are used only for research. CPSC records show that you were treated on «Treatmentdate» in the «HospName» Emergency Department. We may call you to ask questions about your injury or exposure. If you agree to take part in this phone interview, it should take about 30 minutes. There is no reimbursement or direct benefit to you for taking part in this study. The Occupational Safety and Health Act of 1970 authorizes data collection for this study. This study is supported by the International Association of Fire Fighters and the National Volunteer Fire Council.

Your answers to the questions will be kept private to the extent allowed by law. Your answers or any facts that might point to you indirectly will not be reported or published. Your answers may be given to contractors working on this study. They may also be given to other researchers who plan to perform further studies.

While it is very unlikely to occur at any point in this study, a loss of privacy that may lead to mental stress is the only known danger to taking part in this study. Physical injury or harm is not likely. If you are harmed, medical care will not be provided. If you are harmed because of any actions of an interviewer contracted by CPSC, you could file a claim against the contractor.

This study is voluntary. You may choose to be in the study or not. You may choose to answer any or all questions. You may drop out any time for any reason without consequences to you.

If you do not want us to contact you for an interview, call CPSC at (800) 638-8095, extension 7431 within 10 days of getting this letter. Please leave a message. In your message, include your name and the project number at the top of this letter.

Your name, address, and phone number will only be used to get in touch with you for this study. Your name, address, and phone number will be deleted when the interview is completed, if you refuse to participate, or if you cannot be reached within 60 days.

We hope you will help us with this important research so we can reduce injuries and exposures to fire fighters. If you have questions about this study, call the principal investigator, Suzanne Marsh, at (304) 285-6009. For questions about your rights, your privacy, or potential harm, contact the CDC/NIOSH Chair of the NIOSH Institutional Review Board (IRB) in the Human Research Protection Program at 513-533-8591.

Thank you for your time.

Respectfully,

Tom Schroeder

Statistician, Division Director

Division of Hazard and Injury Data Systems

U.S. Consumer Product Safety Commission