Consent Form

Appendix F

Informed Consent

FOR PRETEST 1 ONLY

[Consent Screen 1]

[DISPLAY]

You are one of about 200 people in the United States who are being asked to take a survey about a new medication. The survey will take approximately 20 minutes.

FOR PRETESTS 2-4

[Consent Screen 1]

[DISPLAY]

You are one of about 270 people in the United States who are being asked to take a survey about a new medication. In the survey, you will be shown an ad about a new medication and you will be asked your opinion about it. The survey will take approximately 20 minutes.

[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 Research Now to conduct this survey but is not affiliated with Research Now in any way. If you have questions about this survey, please contact Dr. Linda Squiers, the project director. She can be reached between 9 AM and 5 PM Eastern Standard Time Monday – Friday at 1-800-334-8571 ext. 5129.

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.

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 $5.00 in e-Rewards Currency for completing this survey.

Rights as a Participant

If you have any questions about your rights as a participant, you may wish to contact RTI’s Office of Research Protection at 1-866-214-2043.

Privacy and Confidentiality

As with other surveys you receive from Research Now, 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 Research Now, 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].