Informed Consent Form

Online Survey Informed Consent Form Study Title:

INVESTIGATOR INSTRUCTIONS ARE IN ITALICS and highlighted (in yellow) – The instructions are included to assist in your submission and must be deleted prior to submission

SUGGESTED LANGUAGE in italics and highlighted (in blue) – When a section is optional, suggested language has been included, but may be altered as appropriate.

You are being asked to participate in a research study that is being conducted by ------at the Rutgers University. This is a study in ______that is being conducted by ______.

Purpose of the study: [Include a clear statement that the study involves research, nature of the study, purpose of conducting research, total number of subjects’ involved and brief description of the subject pool]

The purpose of this study is to ______. You will be one of approximately ______subjects.

What will be done? [Include step-by-step explanation of what will be expected from study participants, length and frequency of each study procedure and total time commitment for the subject, location of the research, the instruments/documents that will be used and conditions involved]

You will complete a survey, which will take ______minutes to complete. The survey includes questions about ______. After you complete the questionnaire, we will examine ______and will record information ______(for example, ------). (if applicable)

We expect the study to last about ______. Participation in this study is voluntary. The only alternative to this study is not to participate.

Risks or discomforts: [All potential risks, safeguards that are to be employed to reduce or minimize risks]

______risks are anticipated from taking part in this study. If you feel uncomfortable with a question, you can skip that question or withdraw from the study altogether. If you decide to quit at any time before you have finished the questionnaire, your answers will NOT be recorded.

Benefits of this study: [Please include all direct or indirect benefits. If no benefits accrue to the subject, then include the lager societal benefits]

There is no direct benefit to you for participating in this study. You will be contributing to knowledge about ______. After we have finished data collection, we also will provide you with more detailed information about the purposes of the study and the research findings (if applicable).

Confidentiality: [Include the extent to which subjects will be identifiable, explanation of how the study will provide the utmost confidentiality or anonymity (confidentiality = individual can be identified directly or through identifiers, but the researchers promise not to divulge that information; anonymity = individuals cannot be identified by anyone, including researchers), explanation of the use of study ID/codes (if applicable), explanation of who will have access to the data, describe when data will be destroyed] [If a survey firm is involved, please include who will collect and

1 RESERVED FOR IRB APPROVAL STAMP Version #: DO NOT REMOVE 3.26.14 store the study related data, where will you store the data and who will have access to this data. Please include details about the survey firm.]

Your responses will be kept completely confidential. We will/ will NOT know your IP address when you respond to the Internet survey. We will ask you to include ______when you complete the Internet survey. Your name and address will not be stored with data from your survey or data from your ______. Instead, you will be assigned a participant number ______. The researchers will/will not see your individual survey responses and the results. All information you provide will be treated confidentially. Once data collection is complete, your e- mail address will be shredded and no link between the survey data and identity will exist. There are no foreseeable risks to participation except for the remote possibility that your email address would be inadvertently disclosed. However, the principal investigator has put in place adequate protections for your privacy in that all information provided will be kept confidential by using a randomly generated number code in place of your email address. This code will be kept securely by the research team only until study completion (please include the month and year).

At the end of the survey, we will ask your permission to use ______for professional presentations and publications (if applicable).

Compensation: [Subjects informed whether compensated or not, amount of compensation and if the subjects will be compensated if they do not complete the survey or withdraw from the study. In case the subjects are entered for raffle draw, please indicate what the prize is, how subjects can enter this raffle, who will conduct the drawing, how and how winner will receive the prize]

Withdrawal: Your participation is voluntary; you are free to withdraw your participation from this study at any time. If you do not want to continue, you can simply leave this website. If you do not click on the "submit" button at the end of the survey, your answers and participation will not be recorded. You also may choose to skip any questions that you do not wish to answer. If you click on the “submit” button at the end of the survey, you will be entered in the drawing. The number of questions you answer will not affect your chances of winning the gift certificate (if applicable).

How the findings will be used: The results of the study will be used for ______. The results from the study will be presented in ______, and the results might be published in a ______.

Contact information: If you have concerns or questions about this research study, please contact the PI (name) at (phone number)

If you have questions about your rights as a research subject, please contact the IRB Director at (973)-972-3608 Newark/ (732)-235-9806 New Brunswick/Piscataway.

By beginning the survey, you acknowledge that you have read this information and agree to participate in this research, with the knowledge that you are free to withdraw your participation at any time without penalty.

2 RESERVED FOR IRB APPROVAL STAMP Version #: DO NOT REMOVE 3.26.14