Consumer perceptions as a foundation for CTP positioning initiative

Assent for Participation in a Discussion Group

ADOLESCENT FOCUS GROUP

Please read this consent form carefully. Take time to ask as many questions as you want. If there are any words or information you do not clearly understand, study personnel will be happy to explain them to you. This assent form must be signed before you can participate in the focus group. Your parent/guardian must also sign this form before you can participate.

INTRODUCTION

A company named Affini LLC is conducting discussion groups on behalf of a health promotion agency to better understand adolescents’ thoughts and knowledge about health, health products, tobacco, advertising and marketing. We have invited you to participate in a discussion with other adolescents to share your thoughts and knowledge about these subjects. Your participation in this study involves being in a focus group (discussion group). The focus group will be guided by a professional who is trained to get your opinion and encourage everyone to take part.

Your participation is entirely voluntary.

PURPOSE OF THE RESEARCH STUDY

The purpose of this study is to better understand adolescents' thoughts and knowledge about health, health products, tobacco, advertising and marketing.

INFORMATION ABOUT THE STUDY

This research involves 3 focus groups of about 7-8 adolescents each. If you agree, you will participate in one focus group. This meeting will last approximately two hours. Group conversations will be recorded, and video-taped, and notes will be taken. Only first names will be used to help protect your privacy.

YOUR ROLE IN THE STUDY

Participating in a research study can be an inconvenience to your daily routine. Please consider the study time commitments and responsibilities when you are deciding whether or not you should participate. These include:

• Coming to the study site for the focus group at the planned time;

• Providing truthful information about what you think about the usefulness of the materials for yourself and other adolescents.

PAYMENT

You will receive $30 in cash for participation in the study. Additionally, your parent/guardian will receive $20 for your participation in the study. This will be given to you at the end of the focus group session.

PRIVACY

As part of this study, the study staff may record personal information about you that contains your name and other personal identifiers. Transcripts of focus groups will only include your first name. The collection and submission of the information will strictly follow professional standards of confidentiality and to the fullest extent allowed by law.

RESEARCH QUESTIONS AND CONTACTS

You may freely ask questions about this consent form or the study now or at any time during the study. If you have any questions about the research, or compensation, during this study you may contact the study staff.

VOLUNTARY NATURE OF STUDY

Entering a research study is voluntary. Anyone who is asked to be in a research study may say no. No one has to become a research subject. If you start a research study, you may stop at any time. You do not need to give a reason, and will not be discriminated against or treated differently if you choose not to be in a research study or later decide not

to participate.

Contact Information

If you have any concerns about your participation in this discussion group or have any further questions about the project, contact Ms. Kirsty Afshar at Affini LLC, telephone number (203) 249-2858.

CONSENT STATEMENT BY PARTICIPANT 17 AND UNDER

I have read this consent form. I understand what I am being asked to do. My questions have been answered and any words I did not understand have been explained to me. I agree to be in this research study for the purposes listed above. I will receive a copy of this consent form for my records.

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Print your name here if you want to be in this study

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Sign your name here if you want to Signature Date

be in this study

CONSENT STATEMENT BY PARENT OR GUARDIAN

I have read this consent form. My questions have been answered. I agree to allow my child to be in this research study for the purposes listed above. I will receive a copy of this consent form for my records.

By signing this consent form I am not giving up any of my or my child’s legal rights. I also understand that nothing in this consent is intended to change any applicable federal, state or local laws regarding informed consent.

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Printed Name of Minor Research Subject (Child)

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Name of Guardian (Print) Signature Date

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Name of Person Obtaining Signature Date

Informed Consent

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Name of Person Obtaining Signature Date

Informed Consent

Subject’s Initials_________