Informed Consent (Providers)
[Consent Screen 1]
[DISPLAY]
You are one of about XXX people in the United States who are being asked to take a survey about a new medication. First, we will show you a few ads. Second, we will ask you to complete a survey that will take approximately 30 minutes.
[Consent Screen 2]
[DISPLAY]
This survey is being conducted by RTI International (RTI), an independent nonprofit research organization, on behalf of a public health agency. RTI is working with Research Now to conduct this survey but is not affiliated with Research Now in any way. If you have questions about this survey, please contact Dr. Brian Southwell, the project director. He can be reached between 9 AM and 5 PM Eastern Standard Time Monday – Friday at 1-800-334-8571 ext. 8037.
Possible Risks or Discomforts
We do not expect that any of the survey questions will make you uncomfortable or upset; however, if they do, you can refuse to answer any question or you may take a break at any time during the survey. There is also a potential risk of loss of confidentiality. Every effort will be made to protect your information, but this cannot be guaranteed.
Benefits
Your responses are very important because they will help researchers understand how people make decisions about medications.
Incentive
In appreciation for your time, you will receive an honorarium of $XX for completing this survey.
Rights as a Participant
If you have any questions about your rights as a participant, you may wish to contact RTI’s Office of Research Protection at 1-866-214-2043.
Privacy and Confidentiality
As with other surveys you receive from Research Now, the privacy and confidentiality of your information is of the highest importance, and we are committed to maintaining a secure environment in which you can participate. All information collected in this survey will be kept confidential to the extent provided by law. Your name and your e‑mail address will not be shared outside of Research Now, and they will not be associated with your answers or used in any report.
[Consent Screen 3]
[RADIO]
[PROMPT IF SKIP]
Consent1. If you have read the previous screens and agree to participate, please click the Yes button. If not, click the No button.
Yes, I agree to participate. [Continue with next section]
No, I do not agree to participate. [Go on to next question]
[RADIO]
[PROMPT IF SKIP]
[IF COSNENT1 = NO OR SKIP]
Consent2. Are you sure you don't want to participate? Your opinions are important to us. Please select the Yes button to continue this survey. Select the No button to exit.
Yes, I agree to participate. [continue with next section]
No, I do not agree to participate [end survey].
DHHS research authorized by Section 1701(a)(4) of the Public Health Service Act (42 U.S.C. 300u(a)(4)). Confidentiality protected by 5 U.S.C. 552(a) and (b) and 21 CFR part 20.
OMB Control #_____ Expires _____
| File Type | application/msword |
| File Modified | 2015-03-17 |
| File Created | 2015-03-17 |