Youth Consent 18 and up ExPECTT II

ATTACHMENT 6d: FOLLOW-UP YOUTH CONSENT FORM (18+ Years)

Form Approved

OMB No. 0910-0753

Exp. Date: 01/31/2023

Youth (18+) Follow up Consent Form for the Evaluation of the Public Education Campaign on Teen Tobacco (ExPECTT II)

We are talking to young people all over the United States about a research study sponsored by the U.S. Food and Drug Administration’s Center for Tobacco Products.

The survey asks about tobacco use, media use, and other behaviors that are both legal and illegal. About 4,000 participants are being asked to take this survey. This survey is voluntary and is part of a research study conducted by RTI International.

You will be asked to provide your consent to participate in this survey. Because you are 18 years old or older, it is not necessary for your parent or legal guardian to give their permission for you to take this survey.

To help us protect your information, we have obtained a Certificate of Confidentiality. This means that the researchers cannot provide information that may identify you in a court of law or other legal proceeding. However, researchers may share your information with the FDA or individuals who are responsible for evaluating this study. You should understand that the Certificate does NOT stop reporting that some federal, state or local laws require such as reporting of child abuse, communicable diseases, and threats to harm yourself or others. The Certificate also does NOT prevent your information from being used for other research if allowed by federal regulations. However, no information will be shared or used for other research that could identify you, such as name or date of birth. Finally, you should understand that the Certificate does not prevent you or a member of your family from willingly releasing information about yourself or your involvement in this research.

The survey will last between 35 and 45 minutes, depending on your responses.

You will enter your responses to the questions directly into your computer or other device (e.g., smartphone, tablet). Please take the survey in a place where no one can look over your shoulder and view your answers. Your name will be kept private. Your answers will be labeled with a special number instead of your name so that only RTI research staff will know these are your answers. No one will see your answers to any of these questions. We will not share any information you give us with your parents, or anyone outside the research team. All of your answers will be kept private to the fullest extent allowable by law by the technology used. No absolute guarantees can be made regarding the interception of data sent via the Internet. However, we are taking extensive precautions to protect the confidentiality of your data.

If you don't want to participate in this survey, that is okay. If you don't want to answer a certain question, that is okay too. You may also choose to drop out of the survey at any time, for any reason. If you want to take a break at any time, you can stop and return where you left off when you are ready.

We will mail you a [BEFORE [ADD DATE]] FILL: $30 Visa gift card if you complete the survey on or before [ADD DATE], or a $25 Visa gift card after [ADD DATE]; ELSE ON AND AFTER [ADD DATE]FILL: $25 incentive] to thank you for taking time to complete the survey. You will receive your gift card within 2 weeks of completing the survey.

If you have any more questions about this study, you can call the ExPECTT project assistance line at (800) 608-2955 or email us at [email protected]. If you have a question about your rights as a study participant, you can call RTI’s Office of Research Protection toll-free at (866) 214-2043.

Do you agree to participate in the study?

1      Yes

2      No

OMB No: 0910-0753 Expiration Date: 01/31/2023

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].

CONTACT INFO [IF 18+ CONSENT = 1 (YES)]

Thank you for taking part in this important study. If you complete the survey we will mail you a Visa gift card for [BEFORE AND ON [ADD DATE]FILL: $30] if the survey is completed on or before [ADD DATE], or $25 if it is completed on or after [ADD DATE]; ELSE (ON AND AFTER [ADD DATE]FILL: $25.

We will need to collect some information from you so that we can mail this gift card. This information will be kept completely confidential in secure and protected data files and will be separated from the responses provided in the survey. If you would like to decline receiving this payment, you can leave the information blank and simply press “Next” to continue to the next screen.

Please provide the name and address where we should mail the gift card.

[PROGRAMMER: ALLOW FIELDS TO REMAIN BLANK]

First Name:___________________________________________________

Last Name:___________________________________________________

Mailing Address:

Street _______________________________

City_________________________________

State____________________________________

Zip code___________________________________

____________________________________________

GO TO P_INTRO

ASK: Youth 18+ that have consented to complete online survey.

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