Consent Form

Consent Form - Hep E Virus Exposure.doc

Generic FDA Rapid Response Surveys

Consent Form

OMB: 0910-0500

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Consent for Survey #3: Hepatitis E Virus Exposure

You have been selected at random from adults who donated blood in the calendar year 2014. We thank you for your past donation and invite you to participate in this short survey about your potential exposure to the Hepatitis E virus in the last year. Even if you’ve never gotten Hepatitis E, your responses help public health planners to prepare for potential threats to blood safety. Few cases of Hepatitis E have been identified in the U.S.; however, we are trying to determine the potential for more cases and any impact on the blood supply.

Our questions are not to learn about you individually, but to characterize blood donors in general. Your responses will be anonymous in that we will not collect any information that can identify you.

Participation is voluntary. The questions should only take about 5 minutes to complete. If you have any questions about the study, please call our toll free line at xxx-xxx-xxxx or send an email to xxxxx.

Again, thank you for being a blood donor—your donation has saved lives.

If you consent to participating in this study, click here.



File Typeapplication/msword
AuthorWalderhaug, Mark O
Last Modified ByMizrachi, Ila
File Modified2015-09-24
File Created2015-09-24

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