BodyWorks Follow-up Survey for Parents
Exit this survey
 

Consent Form

 
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0385. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
WHY are we doing this survey? The purpose of this survey is to find out more about parents' experiences with the BodyWorks program. You have been asked to take part in this study because you participated in the BodyWorks program in the past. Your responses can help us improve the program.

WHO is conducting this survey? Shattuck & Associates is conducting this survey for the Office on Women’s Health.

 WHAT am I being asked to do? You will be asked to fill out a survey that will take about 10 minutes. You will be asked about your experiences in the BodyWorks program, if you liked the program, if you thought the program was effective, and some background about yourself.

Your participation is voluntary. You may choose not to participate. If you decide to participate, you change your mind at any time. If you decide not to participate in this study or if you withdraw from participating at any time, there is no penalty.

What are the benefits and risks? The survey was not designed to benefit you personally, but the findings from the research will be used to improve the BodyWorks program for future participants. There are no known risks to participating in this research.

 We will do our best to keep your information confidential. All data is stored in password-protected files. To help protect your confidentiality, the surveys will not contain information that will personally identify you. When we report the findings of the survey, your responses will be summarized with the responses of others.

If you have any questions about the research study or in the event of a research-related injury, please contact:
Michele DeBarthe Sadler, PhD, at Shattuck & Associates, 1313 Scotch Heather Ave., Mt. Airy, MD 21771 or (301) 829-5737
Judith Labiner-Wolfe, PhD at U.S. Department of Health and Human Services, Office of Women’s Health, 200 Independence Avenue SW, Washington DC 20201-0004 or (202) 260-0904

If you have any questions about the rights of a research participant, please contact:
Ethical & Independent Review Services-West Coast, 100 Tamal Plaza, Suite 158, Corte Medera, CA 94925 or subject@eandireview.com or 1-800-472-3241

Image as described above

*
Do you agree to participate in the survey?