0910 Att 10 Survey Questionnaire Consent Frm

Form Approved

OMB No. 0920-0910

Exp. Date 01/31/2024

Emerging Tobacco Products Communication Initiative

Survey Questionnaire Consent Form

Public reporting burden of this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0910).

[Consent Screen 1]

You are one of about 600 educators (e.g., teachers, school administrators, guidance counselors) and coaches in the United States who are being asked to take part in a voluntary study. During the study, you will be shown several advertisements and you will be asked questions about them. We will also ask some questions about your experiences discussing health topics with students. The survey will take approximately 20 minutes.

This study is being conducted by RTI International (RTI), an independent nonprofit research organization, on behalf of the Centers for Disease Control (CDC). RTI is working with Qualtrics to conduct this study but is not affiliated with Qualtrics in any way. If you have questions about this study, please contact Mr. Doug Rupert, the project director. He can be reached between 9 AM and 5 PM Eastern Time on Monday – Friday at 1-800-334-8571 ext. 26495.

Possible Risks or Discomforts

We do not expect that any of the study questions will make you uncomfortable; however, if they do, you can refuse to answer any question. If you skip a question, you can continue with the rest of the study.

Benefits

Your responses are very important because they will help researchers understand how educators respond to different types of advertisements addressing student health concerns. There is no direct benefit to you for your participation.

Incentive

In appreciation for your time, you will receive a $5 Amazon electronic gift card for completing this study.

Rights as a Participant

Your participation is voluntary. If you have any questions about your rights as a participant, you may wish to contact RTI’s Office of Research Protection at 1-866-214-2043.

Privacy and Confidentiality

As with other surveys you receive from Qualtrics, the privacy and confidentiality of your information is of the highest importance, and we are committed to maintaining a secure environment in which you can participate. Your name and your e‑mail address will not be shared outside of Qualtrics unless required by law, and they will not be associated with your answers or used in any report.

[Consent Screen 2]

C1. If you have read the previous screen and agree to participate, please click the “Yes, I agree to participate” button. If not, click the “No, I do not agree to participate” button.

• Yes, I agree to participate. [GO TO SURVEY]

• No, I do not agree to participate. [GO TO C2]

[IF CONSENT1 = NO OR SKIP]

C2. Are you sure you don't want to participate? Your opinions are important to us. Please select the “Yes, I agree to participate” button to continue this survey. Select the “No, I do not agree to participate” button to exit.

• Yes, I agree to participate. [GO TO SURVEY]

• No, I do not agree to participate. [TERMINATE]

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