Fill and Sign the Copy of Affidavit of Financial Information

APPENDIX E: INFORMED CONSENT FORM, IN-PERSON SURVEY (ENGLISH) Hispanic/Latino Adult Tobacco Survey Users’ Guide ADULT TOBACCO SURVEY INFORMED CONSENT FORM Purpose and Benefits The Texas State Health Department is conducting a survey. This survey is to learn about the knowledge, attitudes, and behaviors related to tobacco use. This survey is being done among Hispanic/Latino adults. It is sponsored by the Centers for Disease Control and Prevention. Your taking the survey will help us to identify tobacco use problems and needs in your own community. It will also help to improve services and programs aimed at preventing or decreasing tobacco use and its health effects. Procedures Yearly, we will recruit about 2,250 adults 18 years of age or older to take the survey. The interview will take about 30 minutes to complete. The interview will include general demographic questions. It will also include questions related to tobacco use. Safeguarding Privacy Any information you provide will be maintained in a secure manner. No one but the interviewer will know how you answered the questions. The interviewer has signed a pledge to keep all information about you secure. Your name will be removed from all records involved in the survey. A number will be assigned to the survey questionnaire instead. Only project staff will have access to the study data. We will not use your name when we report results of the survey. The data we collect from you will be combined with data from other adults in El Paso. The combined data will yield a profile of community smoking and health. Risks and Benefits There are no known risks to you as a person taking this survey. There are no known direct benefits to you. However, the overall impact for your community may be great because new data on tobacco use will help to address a crucial health problem. You will receive a $15 gift card to compensate you for your time. Rights as a Volunteer Your taking the Adult Tobacco Survey is your choice. If you feel uneasy with any of the questions, you can refuse to answer. You may also skip questions you do not want to answer. You can stop the interview at any time. If you decide not to take part or to stop the interview, you will not lose any services that you are otherwise receiving. If you have any questions about this survey, you may call [FIELD SUPERVISOR]. You may also call the Project Coordinator, [NAME, TELEPHONE NUMBER]. If you have questions about your rights in taking this survey, you may call [NAME, TELEPHONE NUMBER]. E-2 Appendix E — Informed Consent Form, In-person Survey (English) Respondent Agreement The Adult Tobacco Survey has been explained to me. I consent to participate. I have had a chance for my questions to be answered. I know that I may refuse to participate or to stop the interview at any time without any loss of health care benefits that I am otherwise receiving. I understand that if I have questions about this survey or my rights in taking it, or if I feel I have been injured in this study, I may contact [NAME, TELEPHONE NUMBER]. No funds have been set aside to compensate participants for injuries. __________________________________ Respondent Signature _____________________ Date __________________________________ Interviewer Signature _____________________ Date Copies: Respondent Project Coordinator E-3