Outcome Follow-up Questionnaire in Person

IRB 13819

Attachment 14: longitudinal screener informed consent form

[RESPONDENTS WHO HAVE TAKEN THE SURVEY PREVIOUSLY WILL VIEW THIS SCREEN UPON LOGGING INTO THE MAIN SURVEY. THERE IS A PLACEHOLDER FOR THIS DOCUMENT IN ATTACHMENT 2.]

Form Approved

OMB No. 0910-0808

Exp. Date 01/31/2019

ZA3. [IF LONGITUDINAL (RFU1=1) OR LONGITUDINAL NR (RNE=1)]

The RESPECT LGBT survey asks LGBT young adults about opinions and behaviors related to tobacco and use of media. If you recall, previously you were asked to participate in the study. RTI, a non-profit research organization, is working with the FDA to conduct this study. We are contacting you again to determine whether anything has changed, or if it has stayed the same. Before beginning the study, please answer a few questions to determine whether you are eligible. You are one of approximately 13,000 young adults within 24 cities across the United States that is being asked to complete a short self-administered screening survey to determine eligibility for this study this [FILL: fall/spring/summer]. Your answers to the questions will be kept private to the fullest extent allowable by law, and your participation is voluntary. If we determine you are eligible for the study, you will have the opportunity to complete one or more additional online surveys on your own as part of this study for $20-$25 each.

Do you consent to participate in this survey?

1. Yes, I consent to participate in this survey  GO TO Z0 IN THE LONGITUDINAL SCREENER ATTACHMENT 13

2. No, I do not want to participate in this survey – GO TO CONSENTREF

ASK: All respondents who have taken the survey previously.

CONSENTREF Thank you for your time.

ASK: Respondents who select No to ZA3 (longitudinal screener consent)

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