Attachment C Consent Form

National Worker Well-being Survey

CONSENT FORM: SURVEYS (Information Sheet)

Project Title	
Operationalizing Well-being for the NIOSH Total Worker Health Program	

Purpose of the Study	
This is a research project being conducted by Drs. Vivian Towe and Ramya Chari at the RAND Corporation. This study is funded by the Centers for Disease Control and Prevention. You are invited to participate in this research project because you are a working adult in the United States. The purpose of this research project is to develop a tool to measure worker well-being in the United States.
Worker well-being can be defined as the quality of life with respect to an individual’s health and work-related environment, organizational, and psychosocial factors.	

Procedures	
Participants will complete the following survey by X YY, 2016 electronically. Surveys will be completed remotely, at the respondent’s convenience. Participants include working adults (18+) in the United States.

Completing this survey should take approximately 20 minutes. We will not collect personally identifiable information, and your answers cannot be linked back to you. This survey contains questions related to your experience with your work. Question types include multiple choice (single and multi answer options) and fill in the blank questions. You can skip any questions on the survey that you do not want to answer.

This survey does not require the assistance of outside resources. Completing the questions to the best of your ability, or based on minimal information searching, is acceptable for this survey.	

Potential Risks and Discomforts	
There are no identifiable risks associated with this survey. All information will be kept secure. Your name will not be collected or linked to the data you provide at any time. The researchers will provide an electronic copy of this written consent directly to all research participants prior to conducting the survey.	

Potential Benefits	
This research is not designed to help you personally, but the results may help improve organizational policies, programs, and practices to promote health and prevent disease for employees. We hope that, in the future, other people and organizations might benefit from this study through improved understanding of this phenomenon.	

Data security 	
We will not collect any identifiable information, thus security will be maintained. Should you choose not to participate in the study, information on your refusal to participate will not be released to the organization sponsoring this research project and/or your supervisor. The data collected through this survey will be summarized in aggregate form, grouped with data others provide for reporting and presentation.

Additionally, Federal representatives may have access to research procedures from this project in order to perform routine research compliance checks. However, they will also have no personally identifiable information on respondents who completed this survey. Survey responses will be securely stored on the investigators’ password protected computers and password protected shared drive. Any hard copies of the data will remain in the possession of the principal investigator at her locked office. All data will be destroyed (i.e., shredded or erased) when their use is no longer needed but not before minimum of five years after data collection.	

Token of Appreciation	
You will receive your standard panel token of appreciation for completing this survey.	

Right to Withdraw and Questions	
Your participation in this research is completely voluntary. You may choose not to take part at all. If you decide to participate in this research, you may stop participating at any time

If you decide to stop taking part in the study, if you have questions, concerns, or complaints, or if you need to report an injury related to the research, please contact the RAND Corporation’s Human Subjects Protection Committee (HSPC) toll free at (866)-697-5620 or by emailing hspcinfo@rand.org.	
Participant Rights	
If you have questions about your rights as a research participant or	

	wish to report a research-related injury, please contact:

RAND Corporation
Human Subjects Protection Committee 1776 Main Street
Santa Monica, California, 90401 E-mail: hspcinfo@rand.org Telephone: (866)-697-5620

If possible, when you contact the Committee, please reference Study #2016-0733. This research has been reviewed according to the RAND Corporation HSPC procedures for research involving human subjects.