Consent Form

Clinician and Pharmacist Surveys

Dear Participant:

The National Institute on Drug Abuse, part of the National Institutes of Health, is supporting the development a CME/CE that addresses adolescent substance use.

We ask that you take part in this 7 minute survey to help us identify the information that would be most useful to you and your colleagues regarding early intervention for substance use with adolescent patients and their parents. Your participation in the survey is completely voluntary.

No personally identifiable information will be associated with your responses and there will be no public reporting of this data. All information you provide will be kept private to the extent allowable by law.

Thank you in advance for taking completing this brief survey.

For direct access to the survey please visit [will insert direct link to survey here]. This link will be active until [insert date 3 days after survey launch].

Sincerely,

Elisabeth Davis

Public Health Analyst, National Institute on Drug Abuse, NIH

Project Officer

davise2@nida.nih.gov

(301) 594-6317

Adolescent Survey

Dear [Enter first name]:

Your opinion is very valuable to us. You will receive [insert # of points] points as compensation for your time in participating in this short survey. [insert survey link]

The National Institute on Drug Abuse (NIDA), part of the National Institutes of Health, Department of Health and Human Services, is the Federal government’s agency that researches drug use and addiction.

We are creating an education program for doctors, nurses, and other health care professionals on how to treat adolescents who may be at-risk for or are using drugs.

None of the questions in this survey are about what you do or don’t do. The questions are about how you might feel about doctors, nurses, and other health care professionals sharing drug abuse information with you.

The information you provide will only be used by NIDA and the educational design team. None of your answers will be released publically or shared with anyone else. Your participation will help to ensure that the training program we develop will take into account what teens think and care about. [Insert link to survey here]

Your answers will be kept private to the extent allowable by law.

Thank you for you participation!

Sincerely,

Elisabeth Davis

Public Health Analyst, National Institute on Drug Abuse, NIH

Project Officer

davise2@nida.nih.gov

(301) 594-6317