Implied Consent Form

Informed Consent Form for Social Science Research
The Pennsylvania State University


Principal Investigator: Dr. Lauren Jacobson
3000 Ivyside Park
Altoona, PA 16601

1. Purpose of the Study: The purpose of this research study is to gather information about what businesses in the Blair County area drug test their employees.

2. Procedures to be followed: You will be asked to answer a 17 question survey.

3. Discomforts and Risks: There are no risks in participating in this research.

4. Benefits: Participation in this project will allow us determine the number of businesses that drug test in the Blair County area so that there is reliable data available to the community.

5. Duration: It will take about 10 minutes to complete the survey.

6. Statement of Confidentiality: Your participation in this research is confidential. The data will be stored and secured at the psychology lab in the Smith building on the Altoona campus. The Pennsylvania State University’s Office for Research Protections, the Institutional Review Board and the Office for Human Research Protections in the Department of Health and Human Services may review records related to this research study. In the event of a publication or presentation resulting from the research, no personally identifiable information will be shared.

7. Right to Ask Questions: Please contact Dr. Jacobson at 814.949.5333 with questions, complaints or concerns about this research. You can also call this number if you feel this study has harmed you. If you have any questions, concerns, problems about your rights as a research participant or would like to offer input, please contact The Pennsylvania State University’s Office for Research Protections (ORP) at 814.865.1775. The ORP cannot answer questions about research procedures. Questions about research procedures can be answered by the research team.

8. Voluntary Participation: Your decision to participate in this research study is voluntary. You can stop at any time. You do not have to answer any questions you do not want to answer. Refusal to take part in or withdrawing from this study will involve no penalty or loss of benefits you would receive otherwise.

You must be 18 years of age or older to take part in this research study. If you agree to take part in this research study your consent is granted by completing this survey.

Please print a copy of this consent form for your records.

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* 1. What is your sex?

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* 2. What is your age (in years)?

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* 3. What is your highest level of education?

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* 4. What is your race?

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* 5. What is your job title at your company?

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* 6. How long have you been in your current position?

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* 7. What industry sector do you represent?

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* 8. What is the size of the workforce of your organization?

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* 9. Do you drug test your employees?