Consent Form

OMB Control No: 0910-0847 Expiration Date: 12/31/2022

Paperwork Reduction Act Statement: According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0910-0847. The time required to complete this screening document is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

RADARS® System Survey of Non-Medical Use of Prescription Drugs Program

United States 1^st Quarter 2021 Express Stimulant BAA

Questionnaire

Language & Implied Consent

You are asked to take part in this research study. You will represent other people in the United States who are similar to you. This study asks follow up questions concerning some of your responses to a previous survey about your use of medications, tobacco, alcohol, drugs, and other health issues. Your answers about these topics are important. Policymakers and researchers can use information from this study to understand the ways people use medications. This survey should take about 10 minutes to complete.

Taking this survey is voluntary. You do not have to take the survey. If you start to take the survey and change your mind, you may stop. We will only use information you choose to enter into the survey before stopping. There will not be any penalty for not taking the survey or for stopping the survey. You will be paid according to your panel’s policy. We ask that you try to answer all questions. Some questions and sections are designed so that you do not have to answer. Providing honest and careful answers will help the success of the study.

Your name and information collected will be kept secure to the extent required by law. The researchers will not receive any information that can identify you. The survey panel that gives this survey will link a code to you so that the researchers can note if you have taken more than one survey. However, the researchers will never be able to identify you with this code. You may be contacted for future surveys.

This research is covered by a Certificate of Confidentiality from the National Institutes of Health. The researchers with this Certificate may not disclose or use information or documents that may identify you in any federal, state, or local civil, criminal, administrative, legislative, or other action, suit, or proceeding, or be used as evidence, for example, if there is a court subpoena, unless you have consented for this use. Information protected by this Certificate cannot be disclosed to anyone else who is not connected with the research except if it is required by federal, state, or local laws, or used for other scientific research, as allowed by federal regulations protecting research subjects. You should understand that a Certificate of Confidentiality does not prevent you from voluntarily releasing information or documents about yourself or your involvement in this research. These protections apply only to your research records.

RADARS® System, a division of Denver Health and Hospital Authority, conducts this study. For questions or concerns, you may call the research team at (303) 389-1610. For questions about your rights as a research participant, you may call the Colorado Multiple IRB at (303) 724-1055.

A1. I was provided with information about the survey and I was told that information I provide will be kept secure to the extent permitted by law. I choose to take the survey. Instructional Text: Select one. CONFIDENTIAL

Yes 1

No 0