Informed Consent Form 08-0714

OMB No. 0925-0585-01

Exp. Date: 2/28/2011

Informed Consent Form

In-Depth Interviews for Message and Materials Pretesting

The Academy for Educational Development (AED), which has been contracted by the National Institute of Allergy and Infectious Diseases (NIAID) to implement the NIAID HIV Vaccine Research Education Initiative, invites you to share your opinions on messages and materials concerning HIV vaccine research. The goal for collecting this information is to explore community values relative to HIV vaccine research and to assess the usefulness of materials that could be distributed to your community. The information will help NIAID refine and develop effective messages and materials to raise community support for HIV vaccine research. This set of interviews is authorized by the National Institutes of Health and the Public Health Service Act.

[If asked: NIAID’s activities are authorized under 42 USC 285f, wherein is stated, “The general purpose of the National Institute of Allergy and Infectious Diseases is the conduct and support of research, training, health information dissemination, and other programs with respect to allergic and immunologic diseases and disorders and infectious diseases, including tropical diseases.”]

We are interviewing you and other community leaders about the importance of HIV research to your community and discussing the materials, which were sent to you ahead of time. This interview will last approximately one hour. Researchers associated with this project may be observing this interview.

This interview will be recorded and an aggregate report will be prepared for NIAID. The report may be published. Your participation and responses are voluntary, and your individual identification will not be disclosed to anyone but the researchers conducting the study, except as otherwise required by law. This interview poses no risks to you; furthermore, you can refuse to answer any questions or stop the interview at any time.

Because we know this subject matter may be outside the scope of your work, if you agree to participate, you have the option of receiving a one-time payment of $50.00 as a token of appreciation for your time. If you believe that accepting the payment will present a conflict of interest, or if you would like to provide your insights as a service to your community, you may waive the payment option.

OMB No. 0925-0585-01

Exp. Date: 2/28/2011

Verbal Consent

I will read you a list of statements about this interview process. After, I will ask you to say your full name and ask you if you will consent to participate.

I understand and agree that:

• The interview will cover HIV vaccine research, its importance to my community, and will review materials prepared for dissemination to my community.

• The interview will only be used for research purposes.

• There are no negative consequences if I choose not to participate, furthermore I can stop the interview at any time.

• My interview will be audio taped and researchers may observe.

• I have been offered $50.00 as a token of appreciation for participating in the interview. I may also choose to participate without receiving the $50.00.

• I have asked any questions I have about the interview process that is about to take place.

Please state your name: ____________________________________________

Do you, _________________________________ (Name), of _________________________________ (organization), consent to participating in a 45-minute interview discussing HIV vaccine research?

[Circle response] Yes No

[Record date] ___________________________

Do you waive the $50.00 payment option?

[Circle response] Yes (i.e. will not accept payment) No (will accept payment)

Please fill in the mailing information for the check:

Mail (street & number): ________________________________ (Apt. #) _______

(city, State, zip) _________________________________