Electronic Cigarette Survey
Implied Informed Consent Form for Social Science Research
The Pennsylvania State University
Title of Project: Examining the psychological and biological effects associated with the use of electronic cigarette devices
Dr. Stephen Wilson, Assistant Professor of Psychology, 140 Ritenour Building, University Park, PA 16802, (814) 865-6219, email@example.com
Jonathan Foulds, Ph.D., Professor, Division of Health Services Research, Arthur Berg, Ph.D., Assistant Professor, Biostatistics & Bioinformatics, Gang Chen, Ph.D., Assistant Professor, Division of Epidemiology
1. Purpose of the Study: The purpose of this online survey is to improve our understanding of the use of electronic cigarettes (“e-cigs”), including the types of e-cigs people are using, how frequently they are used and whether or not they are being used to replace other types of tobacco use.
2. Procedures to be followed: You will be asked to answer several questions regarding your use of e-cigs, such as how long you have used them and what types of devices you use. You will also be asked questions about your use of tobacco products. If you agree to and are eligible to participate in the lab study you will be contacted and consented for that portion separately.
3. Discomforts and Risks: There are no risks in participating in this survey beyond those experienced in everyday life.
4. Benefits: You will not benefit directly from this research study.
The benefits to society include developing a better understanding of the factors that may contribute to cigarette smoking behavior, as well as the collection of information that may be useful for assisting people who are trying to quitting smoking.
5. Duration/Time: It will take about 15 minutes to complete the survey.
6. Statement of Confidentiality: Your confidentiality will be kept to the degree permitted by the technology being used. No guarantees can be made regarding the interception of data sent via the Internet by any third parties. All possible steps have been taken to assure your privacy. The Pennsylvania State University’s Office for Research Protections, the Institutional Review Board, and the Office for Human Research Protections in the Department of Health and Human Services may review records related to this research study.
7. Right to Ask Questions: Please contact Dr. Stephen Wilson at (814) 865-6219 with questions, complaints or concerns about this research. You can also call this number if you feel this study has harmed you. If you have any questions, concerns, problems about your rights as a research participant or would like to offer input, please contact The Pennsylvania State University’s Office for Research Protections (ORP) at (814) 865-1775. The ORP cannot answer questions about research procedures. Question about research procedures can be answered by the research team.
8. Voluntary Participation: Your decision to be in this research is voluntary. You can stop at any time. You do not have to answer any questions you do not want to answer. Refusal to take part in or withdrawing from this study will involve no penalty or loss of benefits you would receive otherwise.
You must be 18 years of age or older to take part in this research study.
Completion and submission of the survey implies that you have read the information in this form and consent to take part in the research.
Please print off this form to keep for your records.
Page 1 of 15