1. Acknowledgment of Informed Consent

Section I: Identification of Project and Responsible Investigator:

I hereby agree to participate in a research project entitled Smoking Among LGBTQ Individuals to be conducted by Carrie Heyen as principal investigator.

Section II: Participant Rights and Information:

1. Purpose of the Project:
In the lesbian, gay, bisexual, transgender, and questioning population, smoking rates are considerably higher than the general population. Participation in this study involves filling out a questionnaire, which will be anonymous, it will take approximately 15 minutes to complete. By participating in this study, a better understanding of smoking behaviors in the LGBTQ population can be obtained.
2. Description of Risks:
Although it is unlikely that you will experience any discomfort during this study, there are minor risks. Some of the questions are personal and possibly anxiety provoking. If at any time you do not feel comfortable, you may opt out of the study. The study is completely anonymous and there will be no way of identifying you. If you begin to experience any discomfort and need assistance, resources are available through the following organizations: The GLBT National Help Center at www.glnh.org or toll free at 1-888-843-4564. To find assistance near you, please go to glbtnearme.org. For difficulties with mental health, drugs, alcohol, or tobacco use, reachout.com. All of these organizations are available to the general LGBTQ public.
3. Description of Benefits:
By participating in this study, you are helping the understanding of LGBTQ high smoking rates. With this information, better prevention and cessation programs can be develop in order to reduce the rates of smoking in the LGBTQ population. Reducing the smoking rate in the LGBTQ population can indirectly promote overall health in the LGBTQ population.

4. Disclosure of Alternative Procedures:

You have the option of not participating in the survey or discontinuing your participation without penalty. There are no alternative procedures for this research study except for non-participation.

5. Confidentiality of Records:
Your completed surveys will be anonymous. No identifying information will be collected.

6. Contact Information:
If you have any questions about the research project or about your rights and activities as a participant, then please contact the project’s principal investigator, Carrie Heyen by email at ctully@siue.edu. You may also contact Dr. Danice Brown, research study advisor, at danicbr@siue.edu. If you have any questions about your rights or any other concerns, you may also contact Linda Skelton with the SIUE Institutional Review Board at (618) 650-2958 or lskelto@siue.edu.
7. Statement of Voluntary Participation:
Your participation in this study is voluntary. You can choose to withdraw from the study at any time.

8. Statement of Voluntary Participation:

I have read (or someone has read to me) the consent form and I understand the conditions of the study. I have been presented with the opportunity to ask any lingering questions about the study and have had them answered in a satisfactory way. I am voluntarily agreeing to participate in this research study. I understand that I am not giving up any legal right by consenting to take part in this study.


About the Raffle: Once you consent to participate and complete the survey, on the last page will be an email address and a code. The code will change daily, after completing the survey send the code to the email address using the email address you prefer to be contacted. After I finish collecting data (which may take from 1-3 months) I will randomly pick two email addresses. Thank you!

Question Title

* 1. Do you consent to participate in this study?

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