Attachment Q3: Cognitive Interview Assent Form
Individuals under 18 years of age
Understanding Use of Tobacco among Youth
Introduction
The Centers for Disease Control and Prevention (CDC) and NORC at the University of Chicago (NORC) invite you to participate in a project. Please ask questions if there is anything you don’t understand.
What is the purpose of this project?
The purpose of this project is to test and improve questions that will be used in future surveys about tobacco use, including e-cigarettes, social media, and experiences at home and at school. During today’s interview, we’ll show you survey questions. We’re interested in getting your feedback on the survey questions themselves. Your feedback will help us improve the survey questions and our study.
How long will the interview be?
The interview will take about 60 minutes.
What do you want me to do if I decide to be in the interview?
An interviewer from NORC will ask for your thoughts on questions about tobacco products, including e-cigarettes and how to ask questions about personal characteristics.
Are there any risks to me if I decide to be in this project?
There is no known physical risk to you from being in this project. There is a small chance that you might feel uncomfortable by the things that are talked about during the interview. You can say you don’t want to talk about any topic for any reason. You can also stop participating in the interview at any time.
Are there any benefits from being in this project?
There is no direct benefit to you for being in this project. What we learn from the project will help CDC better understand how people think about tobacco products, including e-cigarettes.
How will the information I give you be kept private?
Some of the people working on the project may watch the interview through a one-way mirror or may listen through the phone to take notes. The interview will be audio recorded so that we can create an accurate set of notes using your words. To keep what you say private, we will not use your name in any interview notes and your name will not be linked to any of your responses. All information that we collect during the interview will be treated in a secure manner. We will destroy the recording and the interview notes at the end of the project. Every effort will be taken to ensure the information you share is kept private but, there is still a small chance that your privacy could be broken.
Who should I call if I have questions about this project?
You may ask questions or express concerns about the project and you can report problems at any time before, during or after the project. You may contact Ashani Johnson-Turbes, Principal Research Scientist at NORC, at 404-240-8411or [email protected].
Who should I call if I have a question about my rights as a volunteer?
NORC is conducting this project on behalf of CDC. If you have any questions about your rights or treatment by the interviewers, please contact NORC’s Institutional Review Board at 1-866-309-0542. Leave a message with your name and phone number and someone will contact you.
Do I have to be in this project?
It’s your choice to be in this project. You can choose not to talk about any topic. You can stop being in the interview at any time without any penalties.
Payment:
We will give you $40 to cover time and transportation costs.
[Verbal assent required.]
Do you provide your permission?
[YES/NO].
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Luciana Rocha |
| File Modified | 0000-00-00 |
| File Created | 2021-01-14 |