Appendix D
Consent Form
[Consent Screen 1]
[DISPLAY]
You are one of about 270 people in the United States who are being asked to take part in a voluntary research survey. 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 Mr. Doug Rupert, the project director. He can be reached between 9 AM and 5 PM Eastern Time on Monday – Friday at 1-800-334-8571 ext. 26495.
Possible Risks or Discomforts
We do not expect that any of the survey questions will make you uncomfortable; however, if they do, you can refuse to answer any question. If you skip a question, you can continue with the rest of the survey. You may take a break at any time during the survey and continue the survey when you return.
Benefits
Your responses are very important because they will help researchers understand how people make decisions about medications. There is no direct benefit to you for your participation.
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 ResearchNow, 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. Your name and your e‑mail address will not be shared outside of Research Now unless required by law, and they will not be associated with your answers or used in any report.
[Consent Screen 3]
[RADIO]
[PROMPT IF SKIP]
C1. 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. [GO TO SURVEY]
No, I do not agree to participate. [GO TO C2]
[RADIO]
[PROMPT IF SKIP]
[IF COSNENT1 = NO OR SKIP]
C2. 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. [GO TO SURVEY]
No, I do not agree to participate. [TERMINATE]
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 #0910-0695 Expires 12/31/2017
| File Type | application/msword |
| Author | Sullivan, Helen W |
| Last Modified By | SYSTEM |
| File Modified | 2017-10-16 |
| File Created | 2017-10-16 |