General population – outcome screener (in person)

Form Approved

OMB No. 0910-0808

Exp. Date 01/31/2019

RIHSC No. 15-108CTP

IRB 13819

Attachment 5: Cross-sectional ScreenEr informed consent FOrm

[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 13,000 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 this [FILL: fall/spring/summer]. 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 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  GO TO A1 IN THE SCREENER FOR CROSS-SECTIONAL INTERCEPT RESPONDENTS (ATTACHMENT 3)

2. No, I do not want to participate in this short screener  GO TO C0S IN THE SCREENER FOR CROSS-SECTIONAL INTERCEPT RESPONDENTS (ATTACHMENT 3)

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

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 13,000 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 [FILL: fall/spring/summer]. 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.

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

1. Yes, I consent to participate in this short screener  GO TO A0 IN THE WEB SCREENER FOR CROSS-SECTIONAL SOCIAL MEDIA RESPONDENTS (ATTACHMENT 3)

2. No, I do not want to participate in this short screener  GO TO REFSCRN IN THE WEB SCREENER FOR CROSS-SECTIONAL SOCIAL MEDIA RESPONDENTS (ATTACHMENT 3)

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]