NIDA Fast Track (OMB Cntrl # 0925-0655)- Consent form Teachers

National Institute on Drug Abuse

Teacher Consent Form

I hereby give my consent to the National Institute on Drug Abuse (NIDA) to participate in a web-based survey of teachers. The survey will be conducted by NIDA’s contractor, Silber and Associates, Clarksville, Maryland. The survey asks for my opinions of the website called NIDA for Teens (http://teens.drugabuse.gov), a government resource for students on drug abuse and addiction. The purpose of the survey is to collect customer satisfaction information that the National Institute on Drug Abuse can use to improve the site.

I understand and agree that the results from the survey will become the property of the National Institute on Drug Abuse but will be anonymous. I understand that my name or any other identifying information will not be used in the study analysis and results, or in any other way, and the National Institute on Drug Abuse will not have access to my name or other identifying information, or my students’ names or other identifying information.

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High School Name City, State

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Teacher’s Printed Name Date

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Teacher’s Signature Date