Adolescent Screener

OMB #0910-XXXX

Expires XX/XX/XXXX

Experimental Study on Warning Statements for Cigarette Graphic Health Warnings

Appendix C: Youth Assent for Study Participation

We are talking to kids about a survey sponsored by the U.S. Food and Drug Administration’s Center for Tobacco Products.

Your parent or legal guardian has given permission for you to take this survey. The survey asks people what they think about tobacco use. About 2,500 people are being asked to take this survey. This survey is part of a research study conducted by RTI International. The survey will take about 15 minutes.

There are minimal psychological, social, or legal risks to participating in this study. You may or may not feel comfortable answering some of the questions in this survey, such as those about tobacco use. There is no direct benefit to you from participating. However, your responses are very important because they will help researchers understand what people think about tobacco use.

Every effort will be made so that that no one will be able to know how you answered the questions, not even your parents. However, protection of your information cannot be guaranteed. If you don't want to take the survey, that is okay. If you get to a question you do not want to answer, you can skip it. You can drop out of the survey at any time, for any reason. If you complete the survey, your parent or guardian’s Global Test Market account will be credited with 100 Lifepoints.

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 at (866) 214-2043.

Do you agree to participate in the study?

1. Yes

2. No

[IF YES, GO TO STUDY]

[IF NO, GO TO END]

END

Thank you for your time.

Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 15 minutes per response to complete this 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.