5b Welcome to the Health and Media Survey

Welcome to the Health and Media Survey

Welcome to the Health and Media Survey

Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/xxxx

Public reporting burden of this collection of information is estimated to average 3 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. 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 OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports
Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx)

BACKGROUND
Thank you for agreeing to take this survey. Our first few questions are primarily for classification purposes and they enable us to select the questions to ask
you later in the survey. They will also help us properly analyze responses to this survey.
What is your age?
years old

How many children aged 17 or younger live in your household 6 months or more of the year?
Number of Children

INTRODUCTION
According to your previous responses, you qualify to participate in a survey that will take about 30 minutes to complete. You will be asked various questions
about nutrition and physical activity as well as a few questions about your background. The goal of this survey, which will include approximately 15,000
individuals nationwide, is to provide more in-depth analysis of mass media efforts and people's reactions to television ads.
Your responses will be maintained in a secure manner and no personal identification information will be passed on to the sponsors of this study. In addition,
your name or other personal information will never be associated with your responses. The data collected for this research study will be combined with that of
all participants before it is analyzed.
There are no physical risks involved in participating in this study; however, it is possible that you could find some of the questions to be sensitive. If you find a
question during the survey to be too personal, you may choose not to answer the question. Your participation is strictly voluntary and you may terminate your
participation at any time. The benefit of participating in this study is to assist the sponsor in estimating awareness of an important media campaign. You will
be awarded $6.25 in e-rewards currency for completing this study.
This survey is being conducted on behalf of the Centers for Disease Control and Prevention and RTI International, a non-profit research organization that
conducts studies on many types of health and social issues. If you have any questions about this study, you can contact RTI's Study Coordinator, Erik
Crankshaw, at 919-316-3809. If you have any questions about your rights as a study participant, you can contact RTI's Human Research Protections Office by
email at [email protected], or by phone at 1-866-214-2043 (a toll-free number). Please print or save a copy of this document for your records.
I have read and understand the information provided above and the study purpose and procedures are clear to me.
Yes, I agree to participate in this study.
No, I do not wish to participate in this study.