Informed Consent

Health Care Professional Survey of Prescription Drug Promotion

HCP Survey_Appendix D_Main Study Informed Consent

Informed Consent

OMB: 0910-0730

Document [docx]
Download: docx | pdf


Informed Consent Form (Main Study)

[Consent Screen 1]


You are one of a number of health care professionals in the United States who are being asked to take a voluntary survey about pharmaceutical promotion. The survey will take about 20 minutes to complete.

[Programmer: The following information must be present on the first page of the informed consent form, the screener and the survey:

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

OMB Control #0910-xxxx. Expires [date].]

[Consent Screen 2]


This survey is being conducted by RTI International (RTI), an independent nonprofit research organization, on behalf of the U.S. Department of Health and Human Services. RTI is working with Knowledge Networks to conduct this survey but is not affiliated with Knowledge Networks in any way. If you have questions about this survey, please contact Panel Relations at 1-800-782-6899, and someone will direct your questions to the appropriate researchers at RTI.

Possible Risks or Discomforts

We do not expect that any of the survey questions will make you uncomfortable or upset; however, if they do, you can refuse to answer any question and you may take a break at any time during the survey.


Your responses are very important because they will help researchers understand how direct-to-consumer advertising affects conversations between patients and their health care professionals.

If you have any questions about your rights as a survey participant, you may wish to contact the RTI Office of Research Protection toll-free at 1-866-214-2043.

As with other surveys you receive from Knowledge Networks, the privacy and confidentiality of your information is of the highest importance, and we are committed to maintaining a secure environment in which you can participate. All information collected in this survey will be kept confidential to the extent provided by law. Your name and your e‑mail address will not be shared outside of Knowledge Networks, and they will not be associated with your answers or used in any report.

[Consent Screen 3]


[prompt if skip]

Consent1. If you have read the previous screens and agree to participate, please click the Yes button. If not, click the No button.

  • Yes, I agree to participate. [continue with next section]

  • No, I do not agree to participate. [go on to next question]


[prompt if skip]

[if consent1=no or skip]

Consent2. Are you sure you don't want to participate? Your opinions are important to us. Please select the Yes button to continue this survey. Select the No button to exit.

  • Yes, I agree to participate. [continue with next section]

  • No, I do not agree to participate [end survey].

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Modified0000-00-00
File Created2021-01-30

© 2024 | Privacy Policy