Adult Consent Form

O MB Control Number: 0925-0675
Expiration Date: 05/31/2016

Consent for Focus Group Participation -
Population Assessment of Tobacco and Health (PATH) Study

You are being asked to take part in a research study conducted by Westat for the National Institutes of Health (NIH) in partnership with the Food and Drug Administration (FDA). Both the NIH and the FDA are part of the U.S. Federal Government. This study is to help us test materials to be used in a study about tobacco use and health in the U.S. population.

As part of the PATH Study, Westat is conducting focus groups tobacco-related content on social media sites. The focus group will last about an hour and a half. When it’s over, you will receive $50 in cash to thank you for your time.

Your participation in this study is voluntary. You may choose not to answer any question, and you can stop participating at any time.

Researchers from the NIH and FDA may be observing the focus group discussion.

There are no known risks to you for taking part in this interview. Your name will never be linked to your comments nor will it appear in any written reports or publications. There are also no direct benefits to you for taking part in this interview, but your answers will help us provide useful information that may lead to improved health policies.

This focus group will be audio-recorded. The recording and all study materials that identify you will be destroyed within three months after this study is completed.

If you have any questions about this study, contact Jocelyn Newsome at 301-212-3734. If you have questions about your rights and welfare as a research participant, please call the Westat Human Subjects Protections office at 1-888-920-7631. Please leave a message with your full name, the name of the research study (PATH Testing) that you are calling about, and a phone number beginning with the area code. Someone will return your call as soon as possible.

I have read the information above about this project and my rights as a participant. I consent to participate in this research and to have this discussion audio taped.

Signature: _____________________________________ Date: ________________

Print Name: ____________________________________

Public reporting burden for this collection of information is estimated to average 4 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0675). Do not return the completed form to this address.