Adult Informed Consent Form

IRB #022819-2

The purpose of this study is to collect information on health and behavioral risk factors of Buffalo County residents. You are invited to participate in an online survey, which will take about 10 minutes of your time. The following information is provided to help you to make an informed decision whether or not to participate.


While some of the questions may deal with sensitive matters of physical or mental health, the survey responses are recorded in such a manner that you cannot be identified. The researchers DO NOT have access to your internet address, or that of the device you are using to complete the survey. In addition, you have the right to skip any questions you don’t want to answer, or to exit the survey at any time by closing out your browser.


By completing this survey, you are performing an important community service. The information gained may help us to better understand what public health risks are prevalent in Buffalo County, and to plan educational or health programming to address those risks. These data may also be used in the future to assess trends in physical health in Buffalo County.

Your rights as a research subject have been explained to you.  If you have any additional questions concerning your rights, you may contact the University of Nebraska at Kearney Institutional Review Board (IRB), telephone 308-865-8843 or 

You are free to decide not to participate in this study or to withdraw at any time without adversely affecting your relationship with the investigators or the University of Nebraska.  Your decision will not result in any loss of benefits to which you are otherwise entitled. 


Dr. Diane L. Duffin (
Dr. Satoshi Machida (
Dr. Charles M. Rowling (
Department of Political Science
University of Nebraska at Kearney

Question Title

By clicking "Yes" below, you are voluntarily making a decision to participate in this study. This certifies that you are at least 19 years old and have decided to participate, having read and understood the information presented. If you have decided not to participate, please select "No" to exit out of the survey.