Concept Testing for Online Pharmacy Communications Campaign

OMB No. 0910-0677

Expires July 31, 2012

Focus Group Discussions: Concept Testing

Informed Consent Form

Public reporting burden for this collection of information 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. Send comments regarding this burden estimate or another aspect of this collection of information, including suggestions for reducing this burden to: Department of Health and Human Services,

Food and Drug Administration
Office of the Chief Information Officer
1350 Piccard Drive, 420A
Rockville, MD 20850

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number.

Booz Allen Hamilton, which has been contracted by the Food and Drug Administration (FDA), invites you to share your opinions on drafts of concepts and messages for a public outreach campaign on purchasing prescription medicines safely. The goal for this exercise is to refine the draft concepts and messages for the campaign.

This discussion will last about 90 minutes. Researchers working on this project may also listen to and/or observe the discussion, and it will also be recorded.

The recordings and observations will be used to prepare a report for the FDA. In the report, you will not be identified by name or any other personal information. The report may be published. Your participation and responses are voluntary, and your responses will not be shared with anyone but the researchers. The research poses no risks to you, and you can refuse to answer any questions or stop participating in the discussion at any time.

The Contractor will comply with additional safeguards for ensuring participant information is kept private to the extent permitted by law.  The last names of the participants will not appear on any focus group materials.  Verbatim quotes included in the final report will not be attributed to an individual.

If you have questions about ordering prescription medicine online, you can contact the FDA at 1-888-INFO-FDA (1-888-463-6332) or find information on their Web site at fda.gov.

I have read the informed consent and understand my rights as a participant.

Print Name:___________________________

Signature:________________________________ Date:_____________

OMB No. 0910-0677

Expires July 31, 2012

Focus Group Discussions: Concept Testing

Informed Consent Form

Participant Copy

Public reporting burden for this collection of information 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. Send comments regarding this burden estimate or another aspect of this collection of information, including suggestions for reducing this burden to: Department of Health and Human Services,

Food and Drug Administration
Office of the Chief Information Officer
1350 Piccard Drive, 420A
Rockville, MD 20850

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number.

Booz Allen Hamilton, which has been contracted by the Food and Drug Administration (FDA), invites you to share your opinions on drafts of concepts and messages for a public outreach campaign on purchasing prescription medicines safely. The goal for this exercise is to refine the draft concepts and messages for the campaign.

This discussion will last about 90 minutes. Researchers working on this project may also listen to and/or observe the discussion, and it will also be recorded.

The recordings and observations will be used to prepare a report for the FDA. In the report, you will not be identified by name or any other personal information. The report may be published. Your participation and responses are voluntary, and your responses will not be shared with anyone but the researchers. The research poses no risks to you, and you can refuse to answer any questions or stop participating in the discussion at any time.

The Contractor will comply with additional safeguards for ensuring participant information is kept private to the extent permitted by law.  The last names of the participants will not appear on any focus group materials.  Verbatim quotes included in the final report will not be attributed to an individual.

If you have questions about ordering prescription medicine online, you can contact the FDA at 1-888-INFO-FDA (1-888-463-6332) or find information on their Web site at fda.gov.

I have read the informed consent and understand my rights as a participant.