Media Tracking Screener

Food and Drug Administration's Research and Evaluation Survey for the Public Education Campaign on Tobacco among LGBT (RESPECT)

Attachment5_ScreenerInformedConsent FU2

Media Tracking Screener

OMB: 0910-0808

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ATTACHMENT 5: SCREENER INFORMED CONSENT


[FOR INTERCEPT RESPONDENTS, THE FOLLOWING TEXT WILL BE PROGRAMMED INTO THE SCREENER ON THE TABLET AND WILL BE THE FIRST SCREEN THAT THE RESPONDENTS SEE UPON BEING HANDED THE TABLET.]

RTI, a non-profit research organization, is working with the FDA to learn more about opinions and behaviors related to tobacco and use of media within the LGBT community. You are one of approximately 25,000 young adults within 24 cities across the United States that is being asked to complete a short self-administered screening survey to determine eligibility for this study. Our questions today will only take about 5 minutes.  Your answers to the questions will be kept private to the fullest extent allowable by law. We will try our best to maintain the privacy of data collected during the study. Still, a breach could occur by accident or as a result of hacking. Your participation is voluntary. You will be provided with $10 in cash after completing this short screening survey. If we determine you are eligible for the study, you will have the opportunity to later complete one or more additional online surveys on your own as part of this study for $20 each. If you have any questions before getting started, please feel free to ask the researcher who gave you this tablet.


C1. Do you consent to participate in this short screening survey?

  1. Yes, I consent to participate in this short screener

  2. No, I do not want to participate in this short screener



[FOR SOCIAL MEDIA RESPONDENTS THE FOLLOWING TEXT WILL BE THE FIRST SCREEN THAT RESPONDENTS SEE UPON LAUNCHING THE SURVEY]

RTI, a non-profit research organization, is working with the FDA to learn more about opinions and behaviors related to tobacco and use of media within the LGBT community. You are one of approximately 25,000 young adults within 24 cities across the United States that is being invited through social media to complete a short self-administered screening survey to determine eligibility for this study. This will only take about 5 minutes.  Your answers to the questions will be kept private to the fullest extent allowable by law. We will try our best to maintain the privacy of data collected during the study. Still, a breach could occur by accident or as a result of hacking. Your participation is voluntary. If we determine you are eligible for the study, you will have the opportunity to complete one or more additional online surveys on your own as part of this study for $20 each.


C1. Do you consent to participate in this short screener?

  1. Yes, I consent to participate in this short screener

  2. No, I do not want to participate in this short screener



OMB No: 0910-0808 Expiration Date: 01/31/2019

Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 5 minutes per response. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to [email protected].




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorGourdet, Camille
File Modified0000-00-00
File Created2021-01-22

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