Media Tracking Screener

Form Approved

OMB No. XXXX-xxxx

Exp. Date xx/xx/xxxx

ATTACHMENT 5: SCREENER INFORMED CONSENT

[FOR INTERCEPT RESPONDENTS, THE FOLLOWING TEXT WILL BE PROGRAMMED INTO THE SCREENER ON THE TABLET AND WILL BE THE FIRST SCREEN THAT THE RESPONDENTS SEE UPON BEING HANDED THE TABLET.]

RTI, a non-profit research organization, is working with the FDA to learn more about opinions and behaviors related to tobacco and use of media within the LGBT community. You are one of approximately 20,000 young adults within 24 cities across the United States that is being asked to complete a short self-administered screening survey to determine eligibility for this study. Our questions today will only take about 5 minutes.  Your answers to the questions will be kept private to the fullest extent allowable by law, and your participation is voluntary. You will be provided with $10 in cash after completing this short screening survey. If we determine you are eligible for the study, you will have the opportunity to later complete one or more additional online surveys on your own as part of this study for $20-$25 each. If you have any questions before getting started, please feel free to ask the researcher who gave you this tablet.

C1. Do you consent to participate in this short screening survey?

1. Yes, I consent to participate in this short screener

2. No, I do not want to participate in this short screener

[FOR SOCIAL MEDIA RESPONDENTS THE FOLLOWING TEXT WILL BE THE FIRST SCREEN THAT RESPONDENTS SEE UPON LAUNCHING THE SURVEY]

RTI, a non-profit research organization, is working with the FDA to learn more about opinions and behaviors related to tobacco and use of media within the LGBT community. You are one of approximately 6,500 young adults within 24 cities across the United States that is being invited through social media to complete a short self-administered screening survey to determine eligibility for this study. This will only take about 5 minutes.  Your answers to the questions will be kept private to the fullest extent allowable by law, and your participation is voluntary. If we determine you are eligible for the study, you will have the opportunity to complete one or more additional online surveys on your own as part of this study for $20 each.

C1. Do you consent to participate in this short screener?

1. Yes, I consent to participate in this short screener

2. No, I do not want to participate in this short screener

OMB No: 0910-XXXX Expiration Date: XX/XX/XXXX

Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 5 minutes per response. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to PRAStaff@fda.hhs.gov