ࡱ> 9;8a bjbj 4AbAb$$$$$8888L 8XXXXXXXXNPPPPPP$}t$XXXXXt$$XXX$X$XNXNX`!ljn:0A~jAA$<XXXXXXXttXXXXXXXAXXXXXXXXXB : Health Care Worker Injury Prevention Project Informed Consent -- Behavior Observation What is involved: As part of the evaluation, we are observing employees of [insert facility name] to identify safety behaviors with regard to sharps injury and exposure prevention. Observations will be occurring at your facility between _ ______________ and _______________. The information collected from the observations will be used to determine the effects of a safety information campaign on employee behaviors in handling sharp instruments and other standard precautions. These observations will have no impact on your job or employee record and you are free to request that you not be observed. If you choose not to participate or withdrawal, there will be no penalty or loss of benefits. Confidentiality: Your confidentiality will be protected. Information learned through the observations will only be analyzed at the aggregate or group level. Therefore, no individual-level identifying information will be collected that will allow your employer to know your specific behaviors. Risks: Every precaution will be taken to ensure that you do not suffer any risk including loss of privacy and/or physical harm. Your identity will be protected in any information shared with other healthcare professionals. When data are reported, at least three people with the same characteristics will be in each group. Checklists used to guide the observations will not contain any information that will identify you as an individual. Benefits: Your participation in the observations will assist this project in evaluating which interventions were the most effective. The information learned through this evaluation will also assist other healthcare organizations with sharps injury prevention efforts. For More Information: Please contact [insert contact name]: ext. 9999. Take this form with you for reference if you wish. -VXk G I R S V W \ ^ j l   ' > F     !STUƷΧΞΞΧΧ΁΁|xr hXCJhW| hW|5hW|CJaJhXhX>*CJaJh\>*CJaJh0$>*CJaJh0$CJaJhCJaJhW|hW|B*CJaJphh\CJaJhXhXCJaJhXhX5CJaJ hX5 hXCJ hX5CJhX5CJ\*-VWXk  ' = > F   !STUgdW|`gdXgdXgdX$a$gdXU{hXhv05aJhXhX5aJ h0$5aJ21h:p=L/ =!"#$% s2&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH <`< XNormalCJ_HmH sH tH B@B X Heading 1$$@&a$5CJ DA D Default Paragraph FontRiR  Table Normal4 l4a (k (No List LRL XBody Text Indent 2 `CJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w< U  XX S Q 0$W|=Lv0 X\@@UnknownG.[x Times New Roman5Symbol3. .Cx ArialA$BCambria Math"h@u@u3܆i i hhx243QHP)?=L0!xx ,Health Care Worker Injury Prevention Projectrcs1Novicki, Emily (CDC/NIOSH/OD) Oh+'0+$ LX x   0Health Care Worker Injury Prevention Projectrcs1Normal Novicki, Emily (ob/NIOSH/OD)2Microsoft Office Word@@s\@?H@?HiG)VT$m   !1.@Times New Roman--- &2 p0 Health Care Worker        2 p0   12 p0 Injury Prevention Project           2 pU0   @Times New Roman--- %2 0 Informed Consent    2 0 --  2 0   )2 0 Behavior Observation    2 *0     2 `0     2 `0   @Times New Roman--- &2 `0 What is involved:   2 0   @Times New Roman--- _2 80 As part of the evaluation, we are observing employees of     2 0   ,2 0 [insert facility name]   2 ^0   (2 a0 to identify safety   12 `0 behaviors with regard to   12 0 sharps injury and exposur 2  0 e prevention J2 *0 . Observations will be occurring at your     %2 `0 facility between   2 0 _  2 0 _________  2 0 _ 2 0 ___  2 /0 _  2 70   2 :0 and  2 R0 __ 2 b 0 ____________ 2 0 _. 2 0   @2 #0 The information collected from the   @Times New Roman---- @ !u-- @ !sR- --- @2 `#0 observations will be used to determ   (2 10 ine the effects of  J2 *0 a safety information campaign on employee      "2 `0 behaviors in ha 2 Z0 ndling sharp instruments and other standard precautions. These observations will have no      2 `j0 impact on your job or employee record and you are free to request that you not be observed. If you choose     R2 0`/0 not to participate or withdrawal, there will be     2 0j0   2 0m 0 no penalty o &2 00 r loss of benefits  2 00 .  2 00     2 @`0   --- %2 R`0 Confidentiality:   2 R0   ---  2 b`0  0 2 bc0 Your confidentiality will be protected. Information learned through the observations will only be      n2 s`B0 analyzed at the aggregate or group level. Therefore, no individual   2 s0 - D2 s&0 level identifying information will be      2 ` 0 collected th e2 <0 at will allow your employer to know your specific behaviors.      2  0     2 `0   --- 2 `0 Risks:    2 0   ---  2 `0  0 2 c0 Every precaution will be taken to ensure that you do not suffer any risk including loss of privacy    2 `V0 and/or physical harm. Your identity will be protected in any information shared with       2 X0 other  2 v0   2 z 0 healthcare   2 ` 0 professionals 2 ^0 . When data are reported, at least three people with the same characteristics will be in each      2 `l0 group. Checklists used to guide the observations will not contain any information that will identify you as        2 `0 an individual.  2 0     2 `0   --- 2 `0 Benefits  2 0 :   2 0   ---  2 -`0  0 2 -b0 Your participation in the observations will assist this project in evaluating which interventions     2 =`[0 were the most effective. The information learned through this evaluation will also assist      2 =k 0 other health 2 =0 care   P2 N`.0 organizations with sharps injury prevention ef  2 No0 forts.   2 N0     2 _`0   --- ,2 q`0 For More Information:      2 q0   @Times New Roman---  2 `0  0 S2 00 Please contact [insert contact name]: ext. 9999.     2 0   ---  2 `0   ---  2 `0   --- D2 &0 Take this form with you for reference     2  0 if you wish.   2 @0   "System0 0 "--  00//.. ՜.+,0` hp  &NIOSH  -Health Care Worker Injury Prevention Project)Informed Consent -- Behavior Observation Title Headings  !"#$%&'()*+,-./1234567:Root Entry Flj<1Table AWordDocument4SummaryInformation(+DocumentSummaryInformation80CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q