Appendix F – Supplement to Appendix I
Flesch-Kincaid Grade Level = 8.1
Focus Group Consent Form for Community Leaders (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 from young African American women and community leaders of Palm Beach County, Florida so that we can create a program that may help women, who are at risk for HIV/STD infection due to poverty, to improve their incomes and also make healthy decisions about their lives.
We will ask questions related to work and young African American women in your community. Examples of questions are
Types of work available to young African American women in the community
Other economic resources available to young African American women in the community
Differences in income levels throughout the community
Specific unmet economic needs of young African American women
Barriers to young African American women’s success at obtaining/maintaining employment
Relationship between economic need and HIV risk behaviors
Types of economic activity that would be supported by the community
Types of work that would be feasible in the community
Types of work that would be personally satisfying and provide some income
We want to hear what you think. There are no right or wrong answers.
We will ask you these questions during a group discussion. There will be up to 8 individuals from the community in the group. These individuals will be selected because of their leadership roles in the community. There will also be one female group leader, and one female assistant in the same room. The discussion will last about two hours. We will audiotape the discussion and tapes will be later typed into a computer so they can be used for our research. At the end of the group discussion we will give you a short form asking you some basic information. The form will take about 5 minutes to complete. No names will be collected on this form.
Risks
Some things discussed in the group may make you feel uneasy. We respect your right to not answer any questions. Taking part in the group discussion is up to you. You can stop taking part in the discussion at any time.
We will do our best to make the discussions comfortable. We will stress the importance of keeping the group discussion private. Group leaders will ask group members to respect each other’s confidentiality. However, we cannot guarantee that group members will keep information discussed during the group to themselves.
Confidentiality
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, contact information, audio tapes and notes. This information will be destroyed within 6 months after the focus group.
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 group discussion. 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 group discussion 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 group discussion will be audio taped. I will not discuss or share what I have heard outside of this room.
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 P - Supplement to Appendix I
Flesch-Kincaid Grade Level = 8.1
Focus Group Consent Form for Community Leaders (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 from young African American women and community leaders of xxx County, North Carolina, so that we can create a program that may help women, who are at risk for HIV/STD infection due to poverty, to improve their incomes and also make healthy decisions about their lives.
We will ask questions related to work and young African American women in your community. Examples of questions are
Types of work available to young African American women in the community
Other economic resources available to young African American women in the community
Differences in income levels throughout the community
Specific unmet economic needs of young African American women
Barriers to young African American women’s success at obtaining/maintaining employment
Relationship between economic need and HIV risk behaviors
Types of economic activity that would be supported by the community
Types of work that would be feasible in the community
Types of work that would be personally satisfying and provide some income
We want to hear what you think. There are no right or wrong answers.
We will ask you these questions during a group discussion. There will be up to 8 individuals from the community in the group. These individuals will be selected because of their leadership roles in the community. There will also be one female group leader, and one female assistant in the same room. The discussion will last about two hours. We will audiotape the discussion and tapes will be later typed into a computer so they can be used for our research. At the end of the group discussion we will give you a short form asking you some basic information. The form will take about 5 minutes to complete. No names will be collected on this form.
Risks
Some things discussed in the group may make you feel uneasy. We respect your right to not answer any questions. Taking part in the group discussion is up to you. You can stop taking part in the discussion at any time.
We will do our best to make the discussions comfortable. We will stress the importance of keeping the group discussion private. Group leaders will ask group members to respect each other’s confidentiality. However, we cannot guarantee that group members will keep information discussed during the group to themselves.
Confidentiality
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, contact information, audio tapes and notes. This information will be destroyed within 6 months after the focus group.
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 group discussion. 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 group discussion 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 group discussion will be audio taped. I will not discuss or share what I have heard outside of this room.
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 F |
| Author | bbs8 |
| Last Modified By | bbs8 |
| File Modified | 2007-05-18 |
| File Created | 2007-05-18 |