General population – outcome screener (social media)

Food and Drug Administration's Research and Evaluation Survey for the Public Education Campaign on Tobacco among LGBT (RESPECT)

Attachment 5 CrossSectional Screener Inf Con FU3

General population – outcome screener (social media)

OMB: 0910-0808

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IRB 13819


Attachment 5: Cross-sectional ScreenEr informed consent FOrm


[FOR INTERCEPT RESPONDENTS, THE FOLLOWING TEXT WILL BE PROGRAMMED INTO THE SCREENER ON THE TABLET AND WILL BE THE FIRST SCREEN THAT THE RESPONDENTS SEE UPON BEING HANDED THE TABLET.]

RTI, a non-profit research organization, is working with the FDA to learn more about opinions and behaviors related to tobacco and use of media within the LGBT community. 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]. Our questions today will only take about 5 minutes.  Your answers to the questions will be kept private to the fullest extent allowable by law. We will try our best to maintain the privacy of data collected during the study. Still, a breach could occur by accident or as a result of hacking.  Your participation is voluntary. You will be provided with $10 in cash after completing this short screening survey. If we determine you are eligible for the study, you will have the opportunity to later complete one or more additional online surveys on your own as part of this study for $20-$25 each. If you have any questions before getting started, please feel free to ask the researcher who gave you this tablet.

C1. Do you consent to participate in this short screening survey?

  1. Yes, I consent to participate in this short screener GO TO A1 IN THE SCREENER FOR CROSS-SECTIONAL INTERCEPT RESPONDENTS (ATTACHMENT 3)

  2. No, I do not want to participate in this short screener GO TO C0S IN THE SCREENER FOR CROSS-SECTIONAL INTERCEPT RESPONDENTS (ATTACHMENT 3)

[FOR SOCIAL MEDIA RESPONDENTS THE FOLLOWING TEXT WILL BE THE FIRST SCREEN THAT RESPONDENTS SEE UPON LAUNCHING THE SCREENER.]

RTI, a non-profit research organization, is working with the FDA to learn more about opinions and behaviors related to tobacco and use of media within the LGBT community. You are one of approximately 13,000 young adults within 24 cities across the United States that is being invited through social media to complete a short self-administered screening survey to determine eligibility for this study this [FILL: fall/spring/summer]. This will only take about 5 minutes.  Your answers to the questions will be kept private to the fullest extent allowable by law. We will try our best to maintain the privacy of data collected during the study. Still, a breach could occur by accident or as a result of hacking.  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 each.

C1. Do you consent to participate in this short screener?

  1. Yes, I consent to participate in this short screener GO TO A0 IN THE WEB SCREENER FOR CROSS-SECTIONAL SOCIAL MEDIA RESPONDENTS (ATTACHMENT 3)

  2. No, I do not want to participate in this short screener GO TO REFSCRN IN THE WEB SCREENER FOR CROSS-SECTIONAL SOCIAL MEDIA RESPONDENTS (ATTACHMENT 3)

OMB No: 0910-0808 Expiration Date: 01/31/2019

Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 5 minutes per response. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to PRAStaff@fda.hhs.gov

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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorGourdet, Camille
File Modified0000-00-00
File Created2021-01-21

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