Fillable Printable Survey Infomed Consent Form
Fillable Printable Survey Infomed Consent Form
Survey Infomed Consent Form
APPENDIX E: INFORMED CONSENT FORM, IN-PERSON SURVEY
(ENGLISH)
Hispanic/Latino Adult Tobacco Survey Users’ Guide
ADULT TOBACCO SURVEY INFORMED CONSENT FORM
Purpose and Benefits
The Texas State Health Department is conducting a survey. This survey is to learn about the
knowledge, attitudes, and behaviors related to tobacco use. This survey is being done
among Hispanic/Latino adults. It is sponsored by the Centers for Disease Control and
Prevention. Your taking the survey will help us to identify tobacco use problems and needs
in your own community. It will also help to improve services and programs aimed at
preventing or decreasing tobacco use and its health effects.
Procedures
Yearly, we will recruit about 2,250 adults 18 years of age or older to take the survey. The
interview will take about 30 minutes to complete. The interview will include general
demographic questions. It will also include questions related to tobacco use.
Safeguarding Privacy
Any information you provide will be maintained in a secure manner. No one but the
interviewer will know how you answered the questions. The interviewer has signed a pledge
to keep all information about you secure. Your name will be removed from all records
involved in the survey. A number will be assigned to the survey questionnaire instead. Only
project staff will have access to the study data. We will not use your name when we report
results of the survey. The data we collect from you will be combined with data from other
adults in El Paso. The combined data will yield a profile of community smoking and health.
Risks and Benefits
There are no known risks to you as a person taking this survey. There are no known direct
benefits to you. However, the overall impact for your community may be great because new
data on tobacco use will help to address a crucial health problem. You will receive a $15 gift
card to compensate you for your time.
Rights as a Volunteer
Your taking the Adult Tobacco Survey is your choice. If you feel uneasy with any of the
questions, you can refuse to answer. You may also skip questions you do not want to
answer. You can stop the interview at any time. If you decide not to take part or to stop the
interview, you will not lose any services that you are otherwise receiving.
If you have any questions about this survey, you may call [FIELD SUPERVISOR]. You may
also call the Project Coordinator, [NAME, TELEPHONE NUMBER].
If you have questions about your rights in taking this survey, you may call [NAME,
TELEPHONE NUMBER].
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Appendix E — Informed Consent Form, In-person Survey (English)
Respondent Agreement
The Adult Tobacco Survey has been explained to me. I consent to participate. I have had a
chance for my questions to be answered. I know that I may refuse to participate or to stop
the interview at any time without any loss of health care benefits that I am otherwise
receiving. I understand that if I have questions about this survey or my rights in taking it,
or if I feel I have been injured in this study, I may contact [NAME, TELEPHONE NUMBER].
No funds have been set aside to compensate participants for injuries.
__________________________________
Respondent Signature
_____________________
Date
__________________________________
Interviewer Signature
_____________________
Date
Copies:
Respondent Project Coordinator
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