This consent form was developed as part of a study on polio immunisation in Nigeria that is being conducted by Public Health Services and Solutions (PHSS) and The Communication Initiative with the United States Agency for International Development (USAID). The purpose of this study is to identify, quantify, and analyse the combined effects of social and material factors, at the micro-level, that appear to associate with incidence of missed children by household in a given community. The research proposed aims to strengthen understanding of how factors operate in a composite manner to determine the prevailing level at which households with eligible children drop out of, or are missed in the process of, supplementary immunisation activities (SIAs). This research aims to generate more in-depth, localised analysis of factors leading to missed children and to produce that analysis in a way that is easily converted back into locally relevant programme knowledge and practice.

A small sample of content in the consent form follows: "The information we collect is designed to provide insight that may lead to improved health programs in your community. One benefit of your participation is that you will contribute useful information that may be used to improve the overall health of children in Nigeria....Your opinions and experiences are important to us. We want you to be honest and truthful in answering our questions. Some of the questions we will ask might be considered personal, thus you may feel uncomfortable. Your participation is completely voluntary. You may ask us to stop the questions if you are uncomfortable. You may also decline to answer any single question that you do not want to. The answers that you give to the questions in this survey will be kept private."

Click here to download the 3-page consent form in Word format.