Merchant Interview&Youth Focus Groups Reactions to Tobacco Product Flavor Bans

Attachment 7

OMB Control Number: 0910-0674

Expiration Date: 03/31/2016

University of Illinois at Chicago

ASSENT TO PARTICIPATE IN RESEARCH

The City of Chicago Flavored Tobacco Product Ban near Schools

1. My name is Sandy Slater. I am a researcher at the University of Illinois at Chicago.

2. We are asking you to take part in a research study because we are trying to learn more about the smoking behaviors of young people.

3. If you agree to be in this study you will sit down with me and a few other young people to discuss the things you know about the smoking behaviors of people your age and where they might purchase tobacco products. This conversation will be held at UIC in the afternoon or evening and will take about an hour and a half.

4. This conversation will not harm you in any way. Anything you tell me about you or other people you know will be kept confidential. There will be other people in the group that you may or may not know, who will hear your opinions and answers to my questions. We will ask that everyone in the group be respectful of others’ privacy by not sharing anything that is said during the conversation, but we cannot 100% guarantee this. We will not include your name in any reports or presentations thatwe create based on our conversation.

5. By having this conversation with me and the other people in the group, you will be helping us as researchers to understand ways we can help young people stay healthy and smoke-free. You will also receive $30 for your participation in the whole group conversation.

6. Please talk this over with your parents before you decide whether or not to participate. We will also ask your parents to give their permission for you to take part in this study. But even if your parents say “yes” you can still decide not to do this.

7. If you don’t want to be in this study, you don’t have to participate. Remember, being in this study is up to you and no one will be upset if you don’t want to participate or even if you change your mind later and want to stop.

8. You can ask any questions that you have about the study. If you have a question later that you didn’t think of now, you can call me at 312-413-0475 or ask me next time. You may also contact the Office for the Protection of Research Subjects at UIC at 312-996-1711.

9. Signing your name at the bottom means that you agree to be in this study. You and your parents will be given a copy of this form after you have signed it.

________________________________________ ____________________

Name of Subject Date

Signature Age Grade in School

Paperwork Reduction Act Statement: 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. The OMB control number for this information collection is 0910-0674 (expires 03/31/2016). The public reporting burden for this information collection has been estimated to average 10 minutes per response to complete the questions asked in this youth assent form, its corresponding participant form, and the Recruitment Script (the time estimated to read and review). Send comments regarding this burden estimate or any other aspects of this information collection, including suggestions for reducing burden, to PRAStaff@fda.hhs.gov.

Youth Focus Group Assent Form, Version 2

01/26/15 1