Attachment A - Consent Form

OMB Control # 0910-0810 Exp. Date: 10/31/2021

Hookah Purchase Journey: Online Hookah User Survey
CONSENT FORM
Thank you for taking the time to participate in this research study. We are working on a project
to understand how hookah/waterpipe market in the U.S. The study is government funded.

The survey will take up to 20 minutes and you will receive $6.00 for your time. Your
participation is voluntary. You may choose to not answer any question and you can stop this
survey at any time. If you choose to end this survey, you will not receive compensation.

There are no known risks to taking part of the study. All the information that we collect will be
kept private and we will never use your name in our reports. There are also no direct benefits to
taking part, but your answers will help us improve the survey.



[Check box] I consent to participate in this survey



[Check box] I do not consent to participate in this survey

Paperwork Reduction Act Statement: The public reporting burden for this information
collection has been estimated to average 3 minutes per response to review this informed consent
form (the time estimated to read, review, and complete). Send comments regarding this burden
estimate or any other aspects of this information collection, including suggestions for reducing
burden, to PRAStaff@fda.hhs.gov.

1