Teacher Consent

Attachment 7 –

Teacher Consent Form

[TEACHER CONSENT FOR PARTICIPATION IN WEB SURVEY ]

National Institute on Drug Abuse

Permission Form

I hereby give my consent to the National Institute on Drug Abuse (NIDA) to participate in a web-based survey of students and teachers for the study Customer Feedback Information for the NIDA PEERx Videos. The survey will be conducted by NIDA’s Contractor, Strategic Research Associates of Spokane, Washington. The survey asks for my opinions of the PEERx videos on the NIDA website (http://teens.drugabuse.gov), the videos are a government resource for students on prescription drugs misuse. The purpose of the study is to collect information that the National Institute on Drug Abuse can use to evaluate and improve the message of the videos.

I understand and agree that the results from the survey will become the property of the National Institute on Drug Abuse but will be anonymous. I understand that my name or any other identifying information will not be used in the study analysis and results, or in any other way, and the National Institute on Drug Abuse will not have access to my name or other identifying information.

__________________________________ ______________________________

High School Name City, State

__________________________________ ______________________________

Teacher Name Teacher Signature

To take the survey, follow these three steps:

1. Be sure you have signed the consent above - and set it aside to return to your principal along with all the returned permission slips from your students.

2. Go to www.survey.strategicresearch.net/teachersurvey.html and enter the password: PASSWORD on the screen that loads (short URL: bit.ly/lllsjsjs)

3. Provide your responses! The survey takes no longer than 18 minutes for you to complete

If you have any questions about this research effort, or need any technical assistance, please feel free to contact Joanne Vega, the National Institute on Drug Abuse's survey consultant at (888) 554-6960 x203 or by email at [email protected].