Appendix E – Supplement to Appendix H
Flesch-Kincaid Grade Level = 8.4
Individual Interview Consent Form for At Risk Women (Florida)
General Information about the Study
We are asking you to take part in a research study that is being done by the Centers for Disease Control and Prevention (CDC). The purpose of this study is to learn about young African American women living Palm Beach County, Florida so that we can create a program that may help women improve their incomes and also make healthy decisions about their lives. We are particularly interested in the relationship between economic needs and risk for HIV and STDs.
We will ask questions about your work experience, your health, and other questions that are more personal in nature. Examples of questions are
Your work history and questions around how you make your living
Things you need, e.g., housing, food, childcare, transportation
Your relationship history
Exchanging sex for the things you need
Substance use
Going to jail or prison
Health problems and health care needs
We want to hear what you think. There are no right or wrong answers.
We will ask you these questions during an individual interview in a private place where no one else can hear the conversation. A female interviewer will ask you the questions. The interview will last about two hours. We will audiotape the interview and tapes will be later typed into a computer so they can be used for our research. No names will be attached to the tapes and typed up interview. Instead, we will attach a study number to the tapes and typed up interview.
Risks
Some things discussed in the interview may make you feel uneasy. We respect your right to not answer any questions. Taking part in the interview is up to you. You can stop taking part in the interview at any time. If you choose not to participate, it will not impact your right to any services that you receive or are eligible for.
Confidentiality
We will do our best to make the discussions comfortable. The information that you share with us will be kept secure. Tapes of the discussion and notes will be kept in a locked file drawer in the Project Leader’s office at the Centers for Disease Control and Prevention, Atlanta, Georgia.
We will keep your name and contact information in a locked file cabinet in the Palm Beach County Department of Health.
Only project staff will have access to information about you, including your name, study number, contact information, audio tapes and notes. This information will be destroyed within 6 months after the interview.
Benefits
Although there are no direct benefits from being in the study, we believe this work can help young African American women in the south to take good care of themselves and those they care about.
Reimbursement
You will receive $25 for your time and any costs you may have for being in the study.
Persons to Contact
If you have questions about the study, you can contact Dale Stratford, the Project Leader, at the Division of HIV/AIDS Prevention, CDC. She can be reached at (404) 639-6276. If you have questions about your rights as a participant in this research study or if you feel you have been injured or harmed as a result of the study, you can call CDC Human Research Protection Office at 1-(800) 584-8814.
Consent
I agree to be in this individual interview. I have been given a chance to ask questions and I feel that all of my questions have been answered. I know that being in this interview is my choice. I know that after choosing to be in this study, I may leave at any time. I have been told that the interview will be audio taped.
I have been given a copy of this consent form to keep. □
Please check here if you would like to receive results from this study. □
Signature of participant Date
__________________________________________________________________
Signature of researcher Date
Appendix O – Supplement to Appendix H
Flesch-Kincaid Grade Level = 8.1
Individual Interview Consent Form for At Risk Women (North Carolina)
General Information about the Study
We are asking you to take part in a research study that is being done by the Centers for Disease Control and Prevention (CDC). The purpose of this study is to learn about young African American women living in xxx County, North Carolina, so that we can create a program that may help women improve their incomes and also make healthy decisions about their lives. We are particularly interested in the relationship between economic needs and risk for HIV and STDs.
We will ask questions about your work experience, your health, and other questions that are more personal in nature. Examples of questions are
Your work history and questions around how you make your living
Things you need, e.g., housing, food, childcare, transportation
Your relationship history
Exchanging sex for the things you need
Substance use
Going to jail or prison
Health problems and health care needs
We want to hear what you think. There are no right or wrong answers.
We will ask you these questions during an individual interview in a private place where no one else can hear the conversation. A female interviewer will ask you the questions. The interview will last about two hours. We will audiotape the interview and tapes will be later typed into a computer so they can be used for our research. No names will be attached to the tapes and typed up interview. Instead, we will attach a study number to the tapes and typed up interview.
Risks
Some things discussed in the interview may make you feel uneasy. We respect your right to not answer any questions. Taking part in the interview is up to you. You can stop taking part in the interview at any time. If you choose not to participate, it will not impact your right to any services that you receive or are eligible for.
Confidentiality
We will do our best to make the discussions comfortable. The information that you share with us will be kept secure. Tapes of the discussion and notes will be kept in a locked file drawer in the Project Leader’s Office at the Centers for Disease Control and Prevention, Atlanta, Georgia.
We will keep your name and contact information in a locked file cabinet in the xxxx County Department of Health.
Only project staff will have access to information about you, including your name, study number, contact information, audio tapes and notes. This information will be destroyed within 6 months after the interview.
Benefits
Although there are no direct benefits from being in the study, we believe this work can help young African American women in the south to take good care of themselves and those they care about.
Reimbursement
You will receive $25 for your time and any costs you may have for being in the study.
Persons to Contact
If you have questions about the study, you can contact Dale Stratford, the Project Leader, at the Division of HIV/AIDS Prevention, CDC. She can be reached at (404) 639-6276. If you have questions about your rights as a participant in this research study or if you feel you have been injured or harmed as a result of the study, you can call CDC Human Research Protection Office at 1-(800) 584-8814.
Consent
I agree to be in this individual interview. I have been given a chance to ask questions and I feel that all of my questions have been answered. I know that being in this interview is my choice. I know that after choosing to be in this study, I may leave at any time. I have been told that the interview will be audio taped.
I have been given a copy of this consent form to keep. □
Please check here if you would like to receive results from this study. □
Signature of participant Date
__________________________________________________________________
Signature of researcher Date
| File Type | application/msword |
| File Title | APPENDIX E |
| Author | bbs8 |
| Last Modified By | bbs8 |
| File Modified | 2007-05-18 |
| File Created | 2007-05-18 |