Youth Screener and Consent for Online Outcome Survey

Attachment 5C: Parental PERMISSION and YOUTH assent, longitudinal participants age 12 – 17, web survey

(For longitudinal web respondents from lead letter age 12 – 17)

Form Approved

OMB No. 0910-0788

Exp. Date 05/31/2018

PERMISSION

The Evaluation of the Fresh Empire Campaign on Tobacco (EFECT) is a research study designed to collect data from youth in order to understand attitudes and beliefs towards tobacco use, media use, and other behaviors that are both legal and illegal.

If you recall, your [PRELOAD AGE] year-old child, [CHILD’S NAME], was selected to be in this study and has completed one or more surveys previously. This study is being conducted again to measure what might have changed over time or what might have stayed the same.

We are asking your permission for your child’s participation in this follow-up web survey. [CHILD’S NAME]’s participation is voluntary. Like last time, this interview asks about tobacco use, media use, illegal behaviors, opinions about tobacco, and experiences at home and at school. Those who complete it will receive a $25 virtual gift card. [INSERT IF DATE IS EQUAL TO OR BEFORE [INSERT DATE]] Your child will receive an additional $5, for a total of $30, if the survey is completed online by [INSERT DATE].

All of your child’s answers will be kept in strict confidence and used only for statistical purposes. No absolute guarantees can be made because of the technology used for electronic surveys like these, but we are taking extensive precautions to protect the privacy of your child’s data.

There are no physical risks to your child from participating in this interview. It is possible that some questions might make your child mildly uncomfortable, depending on his or her responses.

There are no direct benefits to your child from answering our questions. However, he or she will be contributing to important research related to tobacco use among youth. The information provided will help researchers and policymakers understand the impact and effectiveness of public education activities aimed at reducing tobacco-related death and disease.

We may contact you again to request your permission for your child to participate in additional surveys. Those surveys will also offer $25 as a token of appreciation. You can decide at a later date whether to give your child permission to complete any additional surveys. Your child will also be able to decide whether or not to complete any additional surveys.

If it is all right with you, please ask your child to answer the survey. Please give them privacy so they can answer the questions on their own. If you would rather they take the survey on a different device, they can log in on that device at the website listed in the study letter.

After you select your answer, please press “Next.”

1 Yes, I agree to allow my child to participate in this study.

2 No, I do not want my child to participate in this study.

Form Approved

OMB No. 0910-0788

Exp. Date 05/31/2018

ASSENT

This screen is meant to be read by YOUTHFNAME

Thank you for your continued interest in this study. We are interviewing about 2,100 youth across the nation in this wave of the study. We are asking for your continued participation by completing this survey. You are being asked to participate again, based on your participation in a previous survey.

Your parent or legal guardian has given permission for you to take this survey.

This study is designed to collect data from youth about tobacco use, media use, illegal behaviors, opinions about tobacco, and experiences at home and at school. It takes about 40 minutes to complete, depending on your responses. You will answer the questions online. Your answers will not be shared with your parent or guardian, but please make sure that you are in a private place when you answer the questions. We are only interested in the combined responses from those selected to participate, not just one person’s answers.

You will represent young people in this country who are similar to you. You may choose not to take part in this study, but no one else can take your place. If you decide to continue in this study, we will offer you a $25 virtual gift card when you finish the interview. [INSERT IF DATE IS EQUAL TO OR BEFORE [INSERT DATE]] You will receive an additional $5, for a total of $30, if you complete the survey online by [INSERT DATE].

There are no physical risks to you from participating in this interview. It is possible that some questions might make you mildly uncomfortable, depending on your responses.

There are no direct benefits to you from answering our questions. However, you will be contributing to important research related to tobacco use among youth.

While the interview has some personal questions, your answers will be kept private to the extent allowed by law. We hope that protecting your privacy will help you to give accurate answers. You can quit the interview at any time and you can refuse to answer any questions. No absolute guarantees can be made because of the technology used for electronic surveys like these, but we are taking extensive precautions to protect the privacy of your data.

To help us understand changes over time, we may contact you again in the future. You can decide at a later date whether or not you would like to take any additional surveys. Those surveys will also offer $25 as a token of appreciation.

If you have any questions about the study, you may call our research team at 800-845-6708, or email us at [email protected]. If you have any questions about your rights as a study participant, you may call RTI's Office of Research Protection at 1-866-214-2043 (a toll-free number).

After you select your answer, please press “Next.”

1 Yes, I agree to participate in this study.

2 No, I do not wish to participate in this study.

3