Endorsement II Appx C Informed Consent

Appendix C

Endorser Status and Actual Use in Direct-to-Consumer Television Ads

Informed Consent

OMB Control No. 0910-xxxx

Expiration date: xx/xx/xxxx

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0910-xxxx and the expiration date is x/xx/xxxx. The time required to complete this information collection is estimated to average 2 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information.

Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to [email protected].

Thank you for your willingness to complete the survey. Your contribution is important to us.

This survey asks about prescription drug advertising and how it might affect your attitudes and behaviors. The survey will take about 20 minutes to complete.

Taking part is voluntary and you do not have to answer any questions you do not want to. We respect your privacy. Your personal information will remain private to the fullest extent allowable by law and will not be linked to your answers or used in any report.

There are no known risks for participation in this research study. All information you provide will be treated as confidential. While we will take every precaution to protect your information, there is a small risk that others may gain access to your responses, despite all our best efforts. In the case of a breach of confidentiality, appropriate steps will be taken to notify participants. There are no direct benefits to you for participating in this study. However, you will be helping with an important research study.

This study is being conducted by Westat, a survey research organization, on behalf of the U.S. Food and Drug Administration (FDA). If you have any questions about this research, including why it is being conducted or how the results will be used, please contact us at 1-855-XXX-XXXX or email [EMAIL ADDRESS]. If you have questions about your role as a research participant, please contact the Westat Human Subjects Protections Office at 1-888-920-7631.

Please make sure you are using Microsoft Edge, Chrome, Firefox, or Safari as your web browser. This survey will not work using Internet Explorer.

Do you agree to participate in this survey?

○ Yes, I agree to participate in this survey.  Continue

○ No, I do not agree to participate in this survey.  Terminate