APPENDIX 8
Consent Forms
Phase 1 Pretest Consent Form
[Consent Screen 1]
[DISPLAY]
You are one of about 600 people in the United States who are being asked to take a survey about a new medication. The survey will take about 25 minutes to complete.
[Consent Screen 2]
[DISPLAY]
This survey is being conducted by RTI International (RTI), an independent nonprofit research organization, on behalf of a public health agency. RTI is working with GfK to conduct this survey but is not affiliated with GfK in any way. If you have questions about this survey, please contact Panel Relations at 1-800-782-6899, and someone will direct your questions to the appropriate researchers at RTI.
Possible Risks or Discomforts
We do not expect that any of the survey questions will make you uncomfortable or upset; however, if they do, you can refuse to answer any question or you may take a break at any time during the survey. There is also a potential risk of loss of confidentiality. Every effort will be made to protect your information, but this cannot be guaranteed.
Benefits
Your responses are very important because they will help researchers understand how people make decisions about medications.
Incentive
In appreciation for your time, you will receive 10,000 points for completing this survey.
Rights as a Participant
If you have any questions about your rights as a participant, you may wish to contact the RTI Office of Research Protection. If you contact Panel Relations at 1-800-782-6899 and indicate that you would like to contact the RTI Office of Research Protection, someone will provide you with the appropriate contact information.
Privacy and Confidentiality
As with other surveys you receive from GfK, the privacy and confidentiality of your information is of the highest importance, and we are committed to maintaining a secure environment in which you can participate. All information collected in this survey will be kept confidential to the extent provided by law. Your name and your e‑mail address will not be shared outside of GfK, and they will not be associated with your answers or used in any report.
[Consent Screen 3]
[RADIO]
[PROMPT IF SKIP]
Consent1. If you have read the previous screens and agree to participate, please click the Yes button. If not, click the No button.
Yes, I agree to participate. [Continue with next section]
No, I do not agree to participate. [Go on to next question]
[RADIO]
[PROMPT IF SKIP]
[IF COSNENT1 = NO OR SKIP]
Consent2. Are you sure you don't want to participate? Your opinions are important to us. Please select the Yes button to continue this survey. Select the No button to exit.
Yes, I agree to participate. [continue with next section]
No, I do not agree to participate [end survey].
DHHS research authorized by Section 1701(a)(4) of the Public Health Service Act (42 U.S.C. 300u(a)(4)). Confidentiality protected by 5 U.S.C. 552(a) and (b) and 21 CFR part 20.
OMB Control #_____ Expires _____
Phase 1 Consent Form
[Consent Screen 1]
[DISPLAY]
You are one of about 1,000 people in the United States who are being asked to take a survey about a new medication. The survey will take about 25 minutes to complete.
[Consent Screen 2]
[DISPLAY]
This survey is being conducted by RTI International (RTI), an independent nonprofit research organization, on behalf of a public health agency. RTI is working with GfK to conduct this survey but is not affiliated with GfK in any way. If you have questions about this survey, please contact Panel Relations at 1-800-782-6899, and someone will direct your questions to the appropriate researchers at RTI.
Possible Risks or Discomforts
We do not expect that any of the survey questions will make you uncomfortable or upset; however, if they do, you can refuse to answer any question or you may take a break at any time during the survey. There is also a potential risk of loss of confidentiality. Every effort will be made to protect your information, but this cannot be guaranteed.
Benefits
Your responses are very important because they will help researchers understand how people make decisions about medications.
Incentive
In appreciation for your time, you will receive 10,000 points for completing this survey.
Rights as a Participant
If you have any questions about your rights as a participant, you may wish to contact the RTI Office of Research Protection. If you contact Panel Relations at 1-800-782-6899 and indicate that you would like to contact the RTI Office of Research Protection, someone will provide you with the appropriate contact information.
Privacy and Confidentiality
As with other surveys you receive from GfK, the privacy and confidentiality of your information is of the highest importance, and we are committed to maintaining a secure environment in which you can participate. All information collected in this survey will be kept confidential to the extent provided by law. Your name and your e‑mail address will not be shared outside of GfK, and they will not be associated with your answers or used in any report.
[Consent Screen 3]
[RADIO]
[PROMPT IF SKIP]
Consent1. If you have read the previous screens and agree to participate, please click the Yes button. If not, click the No button.
Yes, I agree to participate. [Continue with next section]
No, I do not agree to participate. [Go on to next question]
[RADIO]
[PROMPT IF SKIP]
[IF COSNENT1 = NO OR SKIP]
Consent2. Are you sure you don't want to participate? Your opinions are important to us. Please select the Yes button to continue this survey. Select the No button to exit.
Yes, I agree to participate. [continue with next section]
No, I do not agree to participate [end survey].
DHHS research authorized by Section 1701(a)(4) of the Public Health Service Act (42 U.S.C. 300u(a)(4)). Confidentiality protected by 5 U.S.C. 552(a) and (b) and 21 CFR part 20.
OMB Control #_____ Expires _____
[Consent Screen 1]
[DISPLAY]
You are one of about 850 people in the United States who are being asked to take a survey about a new health product. The survey will take about 15-30 minutes to complete.
[Consent Screen 2]
[DISPLAY]
This survey is being conducted by RTI International (RTI), an independent nonprofit research organization, on behalf of a public health agency. RTI is working with GfK to conduct this survey but is not affiliated with GfK in any way. If you have questions about this survey, please contact Panel Relations at 1-800-782-6899, and someone will direct your questions to the appropriate researchers at RTI.
Possible Risks or Discomforts
We do not expect that any of the survey questions will make you uncomfortable or upset; however, if they do, you can refuse to answer any question or you may take a break at any time during the survey. There is also a potential risk of loss of confidentiality. Every effort will be made to protect your information, but this cannot be guaranteed.
Benefits
Your responses are very important because they will help researchers understand how people make decisions about health products.
Incentive
In appreciation for your time, you will receive 10,000 points for completing this survey.
Rights as a Participant
If you have any questions about your rights as a participant, you may wish to contact the RTI Office of Research Protection. If you contact Panel Relations at 1-800-782-6899 and indicate that you would like to contact the RTI Office of Research Protection, someone will provide you with the appropriate contact information.
Privacy and Confidentiality
As with other surveys you receive from GfK, the privacy and confidentiality of your information is of the highest importance, and we are committed to maintaining a secure environment in which you can participate. All information collected in this survey will be kept confidential to the extent provided by law. Your name and your e‑mail address will not be shared outside of GfK, and they will not be associated with your answers or used in any report.
[Consent Screen 3]
[RADIO]
[PROMPT IF SKIP]
Consent1. If you have read the previous screens and agree to participate, please click the Yes button. If not, click the No button.
Yes, I agree to participate. [Continue with next section]
No, I do not agree to participate. [Go on to next question]
[RADIO]
[PROMPT IF SKIP]
[IF COSNENT1 = NO OR SKIP]
Consent2. Are you sure you don't want to participate? Your opinions are important to us. Please select the Yes button to continue this survey. Select the No button to exit.
Yes, I agree to participate. [continue with next section]
No, I do not agree to participate [end survey].
DHHS research authorized by Section 1701(a)(4) of the Public Health Service Act (42 U.S.C. 300u(a)(4)). Confidentiality protected by 5 U.S.C. 552(a) and (b) and 21 CFR part 20.
OMB Control #_____ Expires _____
[Consent Screen 1]
[DISPLAY]
You are one of about 4,000 people in the United States who are being asked to take a survey about a new health product. First, we will show you a few ads about different products. Second, we will ask you to complete a 15-30 minute survey about one of the products. In some cases, we may ask you to take a second survey about the product. You will view the ads and complete the surveys in separate sessions.
[Consent Screen 2]
[DISPLAY]
This survey is being conducted by RTI International (RTI), an independent nonprofit research organization, on behalf of a public health agency. RTI is working with GfK to conduct this survey but is not affiliated with GfK in any way. If you have questions about this survey, please contact Panel Relations at 1-800-782-6899, and someone will direct your questions to the appropriate researchers at RTI.
Possible Risks or Discomforts
We do not expect that any of the survey questions will make you uncomfortable or upset; however, if they do, you can refuse to answer any question or you may take a break at any time during the survey. There is also a potential risk of loss of confidentiality. Every effort will be made to protect your information, but this cannot be guaranteed.
Benefits
Your responses are very important because they will help researchers understand how people make decisions about health products.
Incentive
In appreciation for your time, you will receive 12,000-20,000 points for completing this survey.
Rights as a Participant
If you have any questions about your rights as a participant, you may wish to contact the RTI Office of Research Protection. If you contact Panel Relations at 1-800-782-6899 and indicate that you would like to contact the RTI Office of Research Protection, someone will provide you with the appropriate contact information.
Privacy and Confidentiality
As with other surveys you receive from GfK, the privacy and confidentiality of your information is of the highest importance, and we are committed to maintaining a secure environment in which you can participate. All information collected in this survey will be kept confidential to the extent provided by law. Your name and your e‑mail address will not be shared outside of GfK, and they will not be associated with your answers or used in any report.
[Consent Screen 3]
[RADIO]
[PROMPT IF SKIP]
Consent1. If you have read the previous screens and agree to participate, please click the Yes button. If not, click the No button.
Yes, I agree to participate. [Continue with next section]
No, I do not agree to participate. [Go on to next question]
[RADIO]
[PROMPT IF SKIP]
[IF COSNENT1 = NO OR SKIP]
Consent2. Are you sure you don't want to participate? Your opinions are important to us. Please select the Yes button to continue this survey. Select the No button to exit.
Yes, I agree to participate. [continue with next section]
No, I do not agree to participate [end survey].
DHHS research authorized by Section 1701(a)(4) of the Public Health Service Act (42 U.S.C. 300u(a)(4)). Confidentiality protected by 5 U.S.C. 552(a) and (b) and 21 CFR part 20.
OMB Control #_____ Expires _____
| File Type | application/msword |
| File Title | APPENDIX F |
| Author | Aikin |
| Last Modified By | Gittleson, Daniel |
| File Modified | 2013-01-03 |
| File Created | 2013-01-03 |