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American Association for Public Opinion Research

Face-to-Face Interview of Health Status

Written, Documented Consent – Face-to-Face Interview of Health Status


University of _____________

Consent for Participation in Research

“Improving Community Health”


Why am I being asked?


You have been randomly selected from all households in _____ to participate in this community health assessment. In order to decide whether or not you want to be a part of this research study, you should understand enough about the purpose of the research project, and ask any questions you may have before agreeing to participate. You should understand the risks and benefits of participating in order to make an informed decision. This process is known as informed consent. This consent form gives detailed information the community health assessment research project, which will be discussed with you. Once you understand the study, you will be asked to sign this form if you elect to participate in the study.


What is a Community Health Assessment?

A community health assessment is a means of measuring the health status of any given community. This assessment is being funded by ______________ and is being implemented by the ______________. Dr. ___________, from _______________, have worked closely with local community organizations to design a survey instrument that is appropriate to the health needs and concerns of your community.


What is the purpose of this research?

The goal of this study is to determine what people living in six _______ community areas think about a number of health issues, and if there are certain community areas at higher-risk for certain health and medical conditions.


You are one of 1,800 people being asked to participate in this study. A professional and well-trained interviewer from the ___________________ will conduct a one-hour interview with you.


There are two components to this interview. The first part asks general questions that apply to you, your experiences and your health. The second part concerns the health of children under the age of 18 in your household if there are any. This second part, if your household qualifies, will be conducted with an adult who knows the most about this child (which may or may not be you).


What procedures are involved?

The first part of the interview should take approximately 45 minutes to one hour, and the second interview, if your household qualifies, should take approximately 15-20 minutes.


Will I be reimbursed for my participation in this research?

In appreciation for your time, your household will receive $40.00 for the first interview and if your household qualifies $20.00 for the second interview.


Can I withdraw or be removed from the study?

Your participation in this study is voluntary. You may choose to refuse to answer any or all questions asked of you. You also have the right to withdraw from the study at any time without penalty or any effect on your present or future relationship to _____________.


What about privacy and confidentiality?

All information obtained in this study is strictly confidential. Your responses will be identified by a study code number only. Your name, or anyone else’s, will NOT be used for any portion of this study. If any information is published, there will be no information that would identify you as a participant.


What are the potential risks and discomforts?

No more than minimal risk is expected during any phase of this study. Some individuals may experience discomfort when talking about various health and medical conditions; however there will no medical or health interventions offered. All information obtained from the survey will remain strictly confidential.


How do I benefit from participating in this research?

Benefits of this study will help further understand the health and medical conditions of your community area, and will help ____________________ to better serve your needs and direct its resources to these areas.


By signing below, you are agreeing to participate in a research study. Be sure that any of your questions about the study have been answered to your satisfaction, and that you have a thorough understanding of the research. If you have other questions or concerns about the research project, you may contact the Project Coordinator _______________________ or the Principal Investigator, _____________________. If you have any questions about your rights as a research subject or participant in this research study, you may call the Office for Protection of Research Subjects at ______________.


Participant’s Signature:___________________________________________



Print Name:____________________________________________________






Interviewer’s Name:_____________________________________________