Consent Form for Participation in the Hurricane Harvey Registry
Purpose of this Registry
The Hurricane Harvey Registry will collect health, location, and exposure information from Houston area residents. This information can help identify health trends and risks associated with Hurricane Harvey. The registry will also support planning for future natural disasters and policy making by city officials. This project is led by Dr. Marie Lynn Miranda from Rice University. This project is funded by the National Institutes of Health, the Cullen Trust for Healthcare, and the Environmental Defense Fund. Please read this consent form carefully and take your time deciding whether to participate.
Procedures / How the Survey Works
If you choose to participate, you will be asked to complete a web-based survey with questions about you and your experience before, during, and after Hurricane Harvey. Participating in this study is completely voluntary and you may end your participation at any time. Most of the survey questions can be skipped if you do not want to answer them. The data you provide will be saved only after you click the “submit” button. The survey will take approximately 10 minutes. Follow up surveys will be available, but optional. You must be 18 or older to participate in this study.
Data from this survey will be stored securely by IT experts from Rice University. Results of this study will be published, but will not include any information that would identify you or any other participant.
Data from this survey may be made available to other researchers outside of the Harvey Registry team. If researchers wish to use your information, they must have approval from Rice University and their home organization. They will also need to show how their research could benefit the greater Houston community. No one will see your data that does not have permission to see it.
Risks and Benefits
The risks from participating in this study are minimal. However, some questions will ask about your location, activity, and experiences during and following Hurricane Harvey. For some participants, this may be distressing. If you do feel distressed, free 24/7 counseling and support is available from the Red Cross Distress hotline at 1-800-985-5990, or by texting “TalkWithUs” to 66746.
While you may not benefit personally from filling out a questionnaire, the information in the registry will help us understand the health impacts of Hurricane Harvey on the greater Houston area. We will share reports with you that tell you what we are learning from the registry. The reports will also be shared with government officials to guide the response to Harvey and plan for Houston’s future.
Problems, Questions, or Concerns
For questions about the study, or if you have complaints, concerns or suggestions, you may contact Dr. Marie Lynn Miranda or Hien Le at firstname.lastname@example.org. For questions about your rights as a research participant, or to discuss problems, concerns or suggestions related to the research, or to obtain information or offer input about the research, you should contact Stephanie Thomas, Compliance Administrator, at Rice University. Email: email@example.com or Telephone: 713-348-3586. Please reference Rice IRB Number IRB-FY2018-95.
Statement of Consent
"The purpose of this study, procedures to be followed, risks and benefits have been explained to me. I understand that I can contact Dr. Marie Lynn Miranda or Hien Le to discuss problems, concerns, or questions, or to obtain more information. I have read this consent form and agree to be in this study, with the understanding that I may withdraw myself at any time."