APPENDIX G - Informed Consent Form

APPENDIX G

Informed Consent form

[Consent Screen 1]

You are being asked to take a survey about a new medication. The study will help us better understand how people use information about prescription drugs. The survey will take about 20 minutes to complete.

You can earn up to 1,000 reward points, plus an entry into our monthly sweepstakes (with 200+ prizes totaling $5,000).

Some questions are personal and may be considered sensitive in nature. Please remember that your participation is completely voluntary. You can refuse to answer any question. As always please be assured that all of your responses are confidential and strictly follow the guidelines set forth in the Privacy Policy, which can be located at https://www.globalopinionpanels.com/privacy_popup.

If you have questions about this survey, please email marie@synovate.net or call 1-800-745-4267.

This research is authorized by Section 1701(a)(4) of the Public Health Service Act (42 U.S.C. 300u(a)(4)). Confidentiality is protected by 5 U.S.C. 552(a) and (b) and 21 CFR part 20.

OMB Control #_____ Expires _____

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