Adolescent - Main data collection

OMB #0910-NEW

SECTION YA: YOUTH ASSENT

[DISPLAY PLACEHOLDER TEXT “OMB #0910-NEW Expires XX/YY/20XX” IN THE YOUTH ASSENT PAGE, PREFERABLY IN SMALLER GREY FONT IN THE UPPER OR LOWER CORNER (E.G., AS A HEADER OR FOOTER). THIS TEXT WILL BE REVISED WITH THE FINAL OMB NUMBER AND EXPIRATION DATE ONCE APPROVED]

[DISPLAY ON SINGLE SCREEN]

Introduction to the Study

Your parent or legal guardian has given permission for you to take this survey. The survey asks people what they think about tobacco use. About 10,000 people are being asked to take this survey. This survey is part of a research study funded by the U.S. Food and Drug Administration’s (FDA’s) Center for Tobacco Products and conducted by RTI International. First you will answer a few questions, then if you qualify you will complete the survey. The survey will take about 12 minutes today. We will contact you again tomorrow for another survey that will take about 8 minutes. Two weeks later we will contact you one last time for a survey will take about 5 minutes.

Voluntary Participation

If you don't want to take the survey, that is okay. If you get to a question you do not want to answer, you can skip it. You can drop out of the survey at any time, for any reason. If you qualify and complete the survey today, your parent’s Global Test Market account will be credited with 1,000 Lifepoints, if you complete the next survey in a day or two your parent’s Global Test Market account will be credited with an additional 1,000 Lifepoints, and if you complete the final survey in about two weeks, your parent’s Global Test Market account will be credited with another 1,000 Lifepoints.

Risks

There are minimal psychological and social risks to participating in this study. You may or may not feel comfortable answering some of the questions in this survey, such as those about tobacco use.

Benefits

There is no direct benefit to you from participating. However, your responses are very important because they will help researchers understand what people think about tobacco use.

Confidentiality

Every effort will be made so that that no one will be able to know how you answered the questions, not even your parents. However, protection of your information cannot be guaranteed. The information that was collected from you during the screener will kept in a secure database with access only to authorized project staff members. Your answers to the study questions will be combined with answer of many others and reported in the summary form. Any personal information that can be used to identify you is stored in a separate database from your survey responses, and your survey responses will not be linked to your personally identifiable information. Upon completion of the study, we are required to store study data for at least 5 years. Study data will be stored securely on a password-protected computer without any of your personal information. Information from this study may be published in professional journals or presented at scientific conferences, but your identifiable information will not be included in any report or presentation. All research staff are committed to privacy and have signed a Privacy Pledge.

This research is covered by a special protection (called a Certificate of Confidentiality) from FDA. This special protection requires that researchers involved in this study protect your privacy. This means researchers generally cannot provide your name, or any other information that could identify you, to anyone who is not connected with the research. Researchers cannot share this information in court or during other legal proceedings, unless you agree, even if there is a court order for the information. However, in other settings, researchers may share study information that could identify you if:

• you agree to share information (for example, to get medical treatment);

• the study information is used for other scientific research that follows federal law;

• FDA, which is paying for the study, needs information to check how their research money is being spent; or

• a law requires sharing information (for example, when researchers must report to FDA, or if researchers hear threats of harm to others or reports of child abuse).

The Certificate of Confidentiality does not prevent you from sharing any personal information or information about your involvement in this study with others. For example, you can share that you are in this research study or your history of tobacco use.

By participating in this study, you agree not to distribute or share any of the images you see during the study.

Questions

If you have any questions about this study, you can call the Study Coordinator, James Nonnemaker at 919-541-7064. If you have a question about your rights as a study participant, you can call RTI’s Office of Research Protection at (866) 214-2043.

Y_ASSENT. Do you agree to participate in the study?

1. Yes

2. No

[IF YES, GO TO SCREENER]

[IF NO, GO TO END]

END

Thank you for your time.