Informed Consent

We need your help and only a few minutes of your time. The Immunization Partnership is committed to eradicating vaccine-preventable diseases through education, advocacy, and the support of best practices.

We have prepared a research survey for Texas families to help us identify and prioritize issues and strategies to focus on as we work to increase immunization rates throughout Texas. This survey should take about 10-15 minutes to complete. The results of this survey will also be used for scholarly purposes. Findings from the survey will be made available on our website in the Summer of 2019.

There is not expected to be any risk to participating in this research. The survey is anonymous and confidential unless you choose to give us your contact information.

You may not benefit personally from completing the survey, but the results may help Texas families in the future.

There is no cost or payment to you for completing the survey.

Your participation is voluntary. Your alternative is not to complete the survey. You may decide not to participate or to stop participating and your decision will not cause you any penalty or loss of benefits to which you are entitled.

If you have any questions, concerns or complaints about the research study, or if you have a research-related problem, please contact The Immunization Partnership at

This research is being overseen by Western Institutional Review Board (WIRB). WIRB is a group of people who perform independent review of research studies involving human subjects. You may talk to them at (800) 562-4789, if:

- You have questions, concerns, or complaints that are not being answered by the research team.
- You are not getting answers from the research team.
- You cannot reach the research team.
- You want to talk to someone else about the research.
- You have questions about your rights as a research subject.

Information from this study will be given to the sponsor. “Sponsor” includes any persons or companies that are contracted by the sponsor to have access to the research information during and after the study. This information may also be seen by WIRB. Absolute confidentiality cannot be guaranteed.

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* 1. Your signature below indicates that you have reviewed this information and agree to participate in the survey.

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* 2. Today's Date

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