Consent Form

You have been asked to take part in an online survey about a health campaign. If you take part, you will be one of about [INSERT FINAL SAMPLE SIZE] people to do so. RTI International, a non-profit research institute located in North Carolina, is conducting the survey.

Procedures

If you agree to participate, we will ask you to complete a 15-minute online survey. The survey asks questions about a health campaign and for your opinions on some of the advertisements for the campaign. It is your choice to participate in the survey. You will not be contacted in the future about this survey after your participation ends.

Risk/Discomforts and Right to Refuse or Withdraw

There are no known risks to participating in the survey. Although the questions we ask are not meant to be sensitive, there is always a chance that you may feel uncomfortable with some of the questions You can decline to answer any questions for any reason, and you can stop participating at any time without penalty.

Benefits

You will not get any personal benefit from taking part in this study. However, your responses are very important because they will help us understand how people may respond to potential health campaign ads and messages.

Remuneration

We will give you [INSERT AMOUNT OF POINTS] as a token of appreciation for taking part in the study.

Privacy and Confidentiality

The privacy and confidentiality of your information is very important to us, 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. Only [VENDOR NAME] knows your name and e‑mail address; RTI cannot access this information. Only RTI can access the survey data; [VENDOR NAME] cannot access this information. This means that your name and email address cannot be linked to your survey answers.

Persons to Contact

If you have questions about the study, you can call Dr. Linda Squiers at 1-800-334-8571, extension 2-5128. She can be reached between 9 a.m. and 5 p.m., Eastern Standard Time, Monday–Friday. If you have questions about your rights as a participant, you can call RTI’s Office of Research Protection toll-free at 1-866-214-2043.

Consent

I understand that it is my choice to participate in this survey. I may refuse to participate or stop participating without penalty.

Please choose one:

I have read this consent form and agree to participate in the survey.

I have read this consent form and do not want to participate in the survey