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CONSENT FOR SURVEY


Title of Research Study: Latino Community Needs Assessment

Researcher's Contact Information:
Name: Fernando Garcia
Telephone: (706) 272-4600
Email: fgarcia@daltonstate.edu

Introduction
You are invited to take part in a research study conducted by Dalton State College on behalf of the Latin America Association with headquarters in Atlanta, Georgia. You must be at least 18 years of age to participate. Before you decide to participate, please read this document and ask questions about anything that you do not understand.

Description of the Research Study
The purpose of this study is to understand the needs of the Latino community relative to the communities where they live and work. There are no known risks or anticipated discomforts for participating in this study. With your participation, the Latin American Association can best meet the needs of the Latino community. Although direct benefits cannot be guaranteed, the Latin American Association may learn more about community-based factors that affect the well-being of the Hispanic population. There is no compensation for participating nor any penalty for not participating in this study.

Confidentiality
The results of your participation will be confidential. Results will only be reported in aggregate form. All individual responses will remain anonymous. To maintain confidentiality, your responses will be held in strict confidence and identifiable by numbers only. To do so, all survey responses, including any paper surveys, will be kept in a locked box accessible only to researchers. All paper surveys will be destroyed immediately after the data is recorded. Final records will be stored in a password-protected office computer only accessible to researchers at Dalton State College.

Supervised Research
Research at Dalton State College that involves human participants is carried out under the oversight of a campus-wide Institutional Review Board. Questions or problems regarding these activities should be addressed to (706) 272-2675 or to:

    Dr. Bruno Hicks 
    Office of Academic Affairs 
    Dalton State College
    650 College Dr
    Dalton, GA 30720

Question Title

* 1. I agree and give my consent to participate in this research project. The survey should take about 10 minutes or less. I understand that participation is voluntary and that I may withdraw my consent at any time without penalty. Do you consent? (Required)

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