Informed Consent Form

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Informed Consent Form

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INFORMED CONSENT FORM: IPSOS


Title of Project: New Product Evaluation


1. This section explains the study in which you will take part:


This is a study about new consumer products. If you agree to take part in this research, you will be asked to read a print advertisement for a potential new product and answer some questions about that product. The study will take about 20 minutes. You will receive a small token of appreciation for participating.


2. This section describes your rights as a research participant:


  • The purpose of the research and your role in it will be explained. You may ask any questions about the research procedures, and these questions will be answered.

  • Your participation in this research is confidential. At no time will your answers be looked at individually or connected with your name. Only the site where you participate and IPSOS, the coordinator of this study, will have access to your name. To make sure your participation is confidential, only a code number appears on the answer sheet of your questionnaire. Your answers will be combined with other participants from at least 8 different locations.

  • Your participation is voluntary. You are free to stop taking part in the research at any time, or to refuse to answer any specific questions without penalty.


3. This section shows that you give your informed consent to participate in the research:


  • This study and my part in the study have been described and fully explained to me, and I understand the explanation.

  • I have been given a chance to ask whatever questions I may have and all of my questions have been answered so that I am comfortable with them.

  • I understand that I am free to refuse to answer to specific items or questions in person or written.

  • I understand that anything I do or say here will remain confidential with regard to my identity.

  • To the best of my knowledge and belief, I have no physical or mental illness or difficulties that would increase the risk to me of participation in this study.


I ALSO UNDERSTAND THAT I AM FREE TO CHANGE MY MIND AND STOP MY PARTICIPATION AT ANY TIME WITHOUT PENALTY.


__________________________________ ________________________

Signature Date


__________________________________

Name


DHHS research authorized by Section 1701(a)(4) of the Public Health Service Act (42 U.S.C. 300u(a)(4)). Confidentiality protected by 5 U.S.C. 552(a) and (b) and 21 CFR part 20.

OMB Control #_____ Expires _____


INTERVIEWER __________________________________________



FACILITY/MARKET ID____________________________________



RESPONDENT ID NUMBER________________________________


Informed Consent Form


[Consent Screen 1]


You are being asked to participate in a survey about new consumer products. If you agree to take part in this research, you will be asked to read a print advertisement for a potential new product and answer some questions about that product. The study will take about 20 minutes.


You can earn up to 1,000 reward points, plus an entry into our monthly sweepstakes (with 200+ prizes totaling $5,000).


Some questions are personal and may be considered sensitive in nature. Please remember that your participation is completely voluntary. You can refuse to answer any question. As always please be assured that all of your responses are confidential and strictly follow the guidelines set forth in the Privacy Policy, which can be located at https://www.globalopinionpanels.com/privacy_popup.


If you have questions about this survey, please email [email protected] or call 1-800-745-4267.





DHHS research authorized by Section 1701(a)(4) of the Public Health Service Act (42 U.S.C. 300u(a)(4)). Confidentiality protected by 5 U.S.C. 552(a) and (b) and 21 CFR part 20.

OMB Control #_____ Expires _____





File Typeapplication/msword
File TitleINFORMED CONSENT FORM: IPSOS
Authorjuanmanuel.vilela
Last Modified ByDHHS
File Modified2012-06-06
File Created2012-06-06

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