Media Tracking Screener

AttacHMENT 4_E2a2: Youth ASSENT MEDIA TRACKING Survey ExPECTT

Youth Assent for Media Tracking Survey

Evaluation of the Public Education Campaign on Teen Tobacco (ExPECTT)

Form Approved

OMB No. 0910-0753

Exp. Date 09/30/2019

We are talking to kids all over the United States about a research study sponsored by the U.S. Food and Drug Administration (FDA) Center for Tobacco Products.

The survey asks teenagers what they think about tobacco use, media use, and other behaviors. About 6,000 youth are being asked to take this survey. This survey is voluntary and is part of a research study conducted by RTI International.

Your parent or legal guardian has given permission for you to take this survey. The survey will last about 30 minutes, depending on your responses. Lightspeed may invite you to participate in the survey again at a future date. It is up to you to decide if you would like to take any future surveys.

You will enter your responses to the questions directly into the Web questionnaire. Your name will be kept private. We will not share any information you give us with your parents, or anyone outside the RTI-FDA research team. All of your answers will be kept private to the fullest extent allowable by law by the technology used. The security of data sent via the Internet is not guaranteed due to the risk of interception by third parties or the presence of monitoring software installed on the device on which the survey is taken. However, we are taking extensive precautions to protect the privacy of your data.

There are minimal psychological, social, or legal risks to participating in this study. You may or may not feel comfortable answering some of the questions in this survey, such as those about tobacco use. If you don't want to participate in this survey, that is okay. If you don't want to answer a certain question, that is okay too. You may also choose to drop out of the survey at any time, for any reason. If you want to take a break at any time, you can stop and return where you left off when you are ready. If you don’t enter any responses for 10-minutes, you will be automatically logged out. This is to protect your privacy, so nobody will be able to see any survey responses on your screen. For the same reason, it is not possible to move backward through the survey. You can log back in when you are ready. There is no direct benefit to you from participating. However, your responses are very important because they will help researchers understand what people think about tobacco use, media use and other behaviors.

When you have reached the last question in the survey, your parent or guardian will receive 1000 [LifePoints/MySurvey Points]. We have asked that they set aside these [LifePoints/MySurvey Points] to thank you for your time.

If you have any more questions about this study, you can call RTI’s National Field Director, [ADD FIELD DIRECTOR NAME], at [ADD FIELD DIRECTOR PHONE NUMBER], extension [ADD EXTENSION]. If you have a question about your rights as a study participant, you can call RTI’s Office of Research Protection toll-free at (866) 214-2043.

Do you agree to participate in the study?

1 Yes

2 No

[HARD CHECK IF THIS QUESTION ISN’T ANSWERED]

[IF YES, GO TO STUDY]

[IF NO, GO TO END AND SAVE]

2