Consent form

Sponsor / Study Title:	CDC / Menthol-Flavored Tobacco Product Restriction Policy Evaluation
Principal Investigator:	Cathy Lesesne, PhD, MPH
Telephone:	404-270-0513
Address:	Deloitte Consulting, LLC 191 Peachtree St., Ste. 2000 Atlanta, GA 30303

COMMUNITY WEB PANEL SURVEY CONSENT FORM

Informed Consent Statement:

We are asking 5,366 adults aged 18 years or older to complete an online survey asking about knowledge, perceptions, and behaviors related to menthol and non-menthol tobacco products. You are being recruited for this survey because you live in one of the communities selected for this study. This research is funded by and conducted on behalf of the Centers for Disease Control and Prevention (CDC).

 

Taking the survey will cause little or no risk to you, but there may be risks that we cannot predict. There is always a risk that the company managing the survey may experience a data breach. Also, there is a risk of discomfort since some questions may be personal in nature. To reduce both risks, this survey is not collecting any personal data and you can choose not to answer any survey questions that make you uncomfortable. Your answers cannot be traced back to you. Survey results will only be reported in summary form. Survey data will be transferred to CDC’s encrypted, password-protected network for storage for a minimum of three years. All data analysis will be conducted using a de-identified file; your responses will be reported in aggregate in the dissemination materials that will be produced.

 

You will not benefit from taking this survey outside of compensation for your time in the form of Qualtrics awards points, but the survey results may help others in the future by supporting public health programs and services. Participation in this survey is entirely voluntary. There is no penalty if you decide not to participate. Choosing not to answer any questions will not result in penalty or loss of compensation. You can stop taking the survey at any time by closing your web browser window or tab. Upon doing so, you will be removed from the study and your data will not be saved. After you submit the survey, your data cannot be removed from the study. 

If you select, “YES, I will take the survey” you are giving your digital consent to participate in the survey and the survey will begin. The survey is hosted on Qualtrics’s survey platform. It will take about 15 minutes to complete. As noted above, you will receive compensation in the form of awards points upon completion of the survey.

If you do not wish to take the survey please select “NO, I will not take part in the survey.” 

If you have any questions about the survey, please contact Dr. Cathy Lesesne at 404-270-0513 or at [email protected]. If you have questions about the study’s funding, please reach out to Katie Moran at 516-743-7727 or at [email protected]. If you have questions or concerns about the research, you may contact Solutions IRB at 855-226-4472 or at [email protected]. Solutions IRB and other regulatory bodies may review the research materials (e.g., data collection tools, study protocol, de-identified data, etc.).

Please read the section above and check one box.

• YES, I will take the survey.  (1) [Cont. survey] 

• NO, I will not take part in the survey. (2) [End survey]

Certificate of Confidentiality Statement:

This research project has a Certificate of Confidentiality from the Centers for Disease Control and Prevention (CDC). Unless you say it is okay, researchers cannot release information that may identify you for a legal action, a lawsuit, or as evidence. This protection applies to requests from federal, state, or local civil, criminal, administrative, legislative, or other proceedings. As an example, the Certificate would protect your information from a court subpoena.

There are some important things that you need to know. The Certificate DOES NOT protect your information if a federal, state, or local law says it must be reported. For example, some laws require reporting of abuse, communicable diseases, and threats of harm to yourself or others. The Certificate CANNOT BE USED to stop a federal or state government agency from checking records or evaluating programs. The Certificate DOES NOT stop reporting required by the U.S. Food and Drug Administration (FDA). The Certificate also DOES NOT stop your information from being used for other research if allowed by federal regulations. Researchers may release your information when you say it is okay. For example, you may give them permission to release information to insurers, your doctors, or any other person not connected with the research. The Certificate of Confidentiality does not stop you from releasing your own information. It also does not stop you from getting copies of your own information.

The Certificate of Confidentiality will not be used to stop sharing your information for any purpose you have consented to in this informed consent document, such as allowing project staff to store and share information collected from the survey.

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