Consent Form - Questionnaire

Principal Investigator: Jennifer O’Loughlin

Co-Investigators: Gilles Paradis, James Hanley, Rachel F. Tyndale, Joseph DiFranza, & André Gervais

Funded by: National Cancer Institute of Canada

Project Title: Study on the Natural History of Nicotine Dependence: Long term follow-up of the Nicotine Dependence In Teens (NDIT) cohort

Description: The NDIT Study is a prospective investigation of 1293 students recruited from grade 7 classes in 10 Montrealsecondary schools in 1999. Our funding was renewed first in 2002, and then again in 2006. The purpose of this latest extension is to study smoking in young adults and to continue to investigate how sociodemographic, psychosocial, and genetic factors relate to nicotine dependence.

Participation: In this phase, we ask that you accept to complete self-administered questionnaires, the responses of which will be maintained in a database for 15 years. We also ask you to accept that these data (which will be stored with no information that could identify you) be used for additional analyses in the future, either by the same researchers or by other research teams, possibly in link with the DNA data.

Study Procedure: Every year over the next 5 years, you will receive a self-administered questionnaire by mail, which will take 30minutes to complete. Itwill ask you about your experience with smoking cigarettes, as well as about factors known to relate to smoking. You will be asked to return the questionnaires by mail in a stamped, addressed envelope (or online through the Internet if you prefer). If you do not complete the questionnaire, our research team may contact you by telephone to remind you to do so. All identifying information will be removed from the questionnaire andthe data will be entered into an electronic database.

Benefits and Risks: There are no risks or benefits expected for participants in this project. However the results will allow increased understanding of the natural history of nicotine dependence, which will help us to develop more effective strategies to help young adults quit smoking.

Withdrawal from Study: Your participation is completely voluntary. You may withdraw from the study at any time. If you decide to withdraw, there will be no prejudice against you.

PLEASE SIGN ON BACK

Last update: April17th 2007 Page 1/2

Confidentiality: All questionnaire data are completely confidential and will be stored in locked storage areas. The data will not have any identifying information, and will be

identified by a code, which is different from the one used for DNA data. A Master List linking your name to your codes will be kept in locked filing cabinets. Only the researchers and the project coordinator will have access to the codes and the data.

Consent:Please complete the form below to indicate if you will participate in the questionnaire component of the NDIT Study, and return it in the stamped, addressed envelope enclosed. If you have any questions, please contact the Project Coordinator, Erika Dugasat 890-8000 x15858 or by email at thank you for your help in this important project.

Jennifer O’LoughlinErika Dugas

Principal InvestigatorProject Coordinator

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Consent to Participate in the Questionnaire Component of the NDIT Study
Please check either “Yes” or “No” below
Yes, I accept to participate in the self-administered questionnaire component of the NDIT Study
No, I do not accept to participate in the self-administered questionnaire component of the NDIT Study
If you checked “Yes” above, please check either “Yes” or “No” below
Yes, I accept that the data from my questionnaires be included in a database that could be used for other studies in the future.
No, I do not accept that the data from my questionnaires be included in a database that could be used for other studies in the future.
Name of Participant
(Please Print) / Date

Please fill in the box below and return the form in the stamped addressed envelope in the next 7 dayS

Last update: April17th 2007 Page 2/2