Adult Screener

OMB #0910-XXXX

Expires XX/XX/XXXX

Experimental Study on Warning Statements for Cigarette Graphic Health Warnings

Appendix B: Parent or Guardian Permission for Youth Study Participation

Greetings!

We have a new survey and your participation is requested. The survey is meant for children ages 13-17. If your child qualifies and completes the survey, your Global Test Market account will be credited with the Lifepoints stated in the invitation.

A new survey is available

Survey Number: [INSERT SURVEY #]

Reward for Survey Completion: 100 Lifepoints

Start Now!

You may also access the survey by copying the following URL into your browser: [INSERT URL LINK]

Best Regards –

Global Test Market Team

[GO TO PARENT PERMISSION]

PARENT PERMISSION

Introduction to the Study

We are talking to youth and adults about a survey sponsored by the U.S. Food and Drug Administration’s Center for Tobacco Products. The purpose of this study is to understand what people think about tobacco use.

Selection of Youth

About 2,500 youth and adults are being asked to take this survey. We need permission from a parent before we survey your child. Your child may choose whether or not to take the survey.

Types of Questions

The survey will take about 15 minutes. Youth will be asked about their experiences with and opinions about tobacco. Youth will take the survey online.

Voluntary Participation

Your child can refuse to answer any and all questions. Your child can stop the survey at any time. You will receive 100 Lifepoints if your child completes the survey.

Risks

There are no physical risks to your child from taking this survey. It is possible that some questions might make your child mildly uncomfortable, depending on his or her responses.

Benefits

There are no direct benefits to your child from taking the survey. However, he or she will be contributing to important research. Results will help improve public education about the dangers of tobacco.

Privacy

Every effort will be made so that that no one will be able to know how your child answered the questions. However, protection of your child’s information cannot be guaranteed. Your child’s answers will be combined with answers of many others and reported in a summary form. All research staff are committed to privacy and have signed a Privacy Pledge.

Questions

If you have any questions about this study, you can call the Study Coordinator, James Nonnemaker at 919-541-7064. If you have a question about your rights as a study participant, you can call RTI’s Office of Research Protection toll-free at (866) 214-2043.

Do you agree to allow your child to take the survey?

1. Yes

2. No

[IF YES, GO TO P_INTRO]

[IF NO, GO TO END]

P_INTRO

It is important that your child be allowed to answer the questions in privacy. From this point on, your child should be able to read and answer all questions on his or her own. Press “Next” when your child is ready to begin. [GO TO STUDY SCREENER]

END

Thank you for your time.

Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 2 minutes per response to complete this screener survey (the time estimated to read and complete). Send comments regarding this burden estimate or any other aspects of this information collection, including suggestions for reducing burden, to PRAStaff@fda.hhs.gov.

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