Form 1 Consent

Attachment A - SFW Customer Satisfaction Study – Study Landing Page & Consent 03.10.2014

OMB No.: 0925-0046

Expiration Date:  05/31/2016

Collection of this information is authorized by The Public Health Service Act, Section 410 (285) and Section 412 (285a-1). Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be kept private under the Privacy Act of 1974, as amended, 5 U.S.C. 552a (SORN #09-25-0156). Names and other identifiers will not appear in any report of the study. Information provided will be combined for all study participants and reported as summaries.  You are being contacted by the National Cancer Institute to provide feedback on its tobacco cessation website.

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0046). Do not return the completed form to this address.

Smokefree Women Customer Satisfaction Study

You are invited to take part in a customer satisfaction survey to help improve quit smoking resources for women that is funded by the National Cancer Institute (NCI). What we learn from this study will be used to improve NCI’s quit smoking materials for women.

What is the study about?

As part of this study, you will be asked to view quit smoking website content. This requires access to the internet. If you agree to participate you will be asked to complete a screening survey. If you are found to be eligible you will be asked to complete an initial survey. You’ll receive 2 emails per week for 4 weeks, asking you to look at the study website. Use the website link in the emails to access the study site. At the end of 4 weeks, you’ll receive an email asking you to complete the final survey.

What do I get for participating?

As a thank you for participating, you will be entered into a lottery to receive a $20 Amazon e-gift card (sent electronically to the email address you provide below). You must take part in the full 4 week study to get the gift card. If you don’t complete the final survey at the end of the study, you won’t receive the gift card. You must have a working email to be part of this study. You may sign up for the study once. Individuals that try to sign up multiple times will be removed from the study and will not be eligible for the lottery.

Can I participate in the study?

At the end of this page you’ll be asked to provide your email address. Then, we’ll send you a verification email that will take you to the Screener Survey. We’ll ask you a few questions to see if you’re eligible for the study.

How will I give my feedback?

The study will last 4 weeks. At the end of the study you’ll be asked to take the Customer Satisfaction Survey to provide your feedback. Check your email regularly for study information.

What are the risks?

We do not know of any risks related to taking part in this study. If you decide you no longer want to participate, we can send you smoking cessation information made available to you during the study.

Will you keep my answers and information private?

Yes, your responses will be kept private to the extent allowable by law and will only be used for the purpose of this research. Many steps have been taken to protect your information. Identifiable information like your email address will be kept separate from your responses and will not be included in any reports, publications, or presentations. Your email address will be erased when the study ends.

Who do I contact if I have questions?

If you have questions, please contact the study team at:

• Email: XXXX@nih.gov

• Phone: XXX-XXX-XXXX

Your Consent: I have read this entire consent form. I agree to participate in this study if I’m eligible.

I

agree to participate in the screening survey, and if eligible to participate in this study.

I

do not agree to participate in this study. [Terminate]

If you agree to participate, what is your email address? [input box]

After you press submit, you’ll be sent an email to verify your account.

[Submit button]

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