Attachment I_BAA Informed consent form

Attachment I. BAA Informed Consent Form

INFORMED CONSENT

On behalf of the Centers for Disease Control and Prevention (CDC), CATMEDIA, an Atlanta, Georgia, based program management, training, and creative services company, is conducting an online survey with adults to gather feedback on educational materials related to antibiotic use. We hope to use what we learn from these survey results to improve these materials and/or how and where we promote them to raise awareness within your community. We expect this survey to take about 20 minutes. You will only be asked to complete this survey once.

Your participation in this survey is completely voluntary. You may choose to skip questions that you do not want to answer and/or stop the survey at any time for any reason. Refusal to participate will not result in any penalties. 

If you choose to participate in this survey, we will keep your answers private and will not share your personal information with anyone outside of the survey team.

At the end of the survey, you will receive [$25 if Consumer or $75 if HCP] through Venmo or PayPal, (electronic delivery) or a gift card as a token of our appreciation for your time. You should receive it within 7 business days.  

If you have questions, please email [name] at [email address] or call XXX-XXX-XXXX or XXX-XXX-XXXX.

Please answer the question below. If you select “Yes,” it means you understand the information in this consent form and that you agree to take the survey.

Do you agree to participate in the survey?  Yes  No

Enter your full name here	Today’s Date

Programmer: If the respondent selects “Yes” to the question, “Do you agree to participate in this survey” and enters their name and date, present the ELIGIBILITY MESSAGE, else present the INELIGIBILITY MESSAGE.

Eligibility Message

Thank you for giving your consent to participate in this survey. If you have any questions, please contact [name] at [email address] or call phone number XXX-XXX-XXXX or XXX-XXX-XXXX.

We appreciate your time. Please click “Enter Survey” to proceed to the survey.

Ineligibility Message 

Thank you for your willingness to participate in this survey. Unfortunately, you are not eligible to proceed with the survey. If you have any questions, please contact [name] at [email address] or call phone number XXX-XXX-XXXX or XXX-XXX-XXXX.

Thank you for your time. Please click on “Exit Survey” to exit.