Appendix05

APPENDIX 5: PHASE 1 INFORMED CONSENT FORM

Note to reviewers: For ease in reviewing this document, we have added and highlighted the required IRB elements. These highlighted items will be removed prior to cognitive interview commencement and, therefore, will not be included in the consent form the subject sees and hears.

Assurance of Privacy and Informed Consent Form

Cognitive Interview

We would like you to take part in a research project funded by the Centers for Disease Control and Prevention. The study will be conducted by the National Opinion Research Center at the University of Chicago. It will collect information about women’s health within minority communities. I will ask questions about violence and sexual violence you may have suffered. We are interested in how the violence has affected your health. Health surveys are tested before they are considered final. It is important that the questions make sense. It is also important that everyone understands the questions the same way. We will ask you to answer a series of questions. After that, we will ask you to explain what you were thinking before you answered the questions; how you came up with your answers [Study Purpose]. First, I will tell you about the study. Then, I will tell you what we will need from you. If you agree to be interviewed, you will be asked to sign this consent form before the interview begins.

The interview will take about 2 hours to complete. I will give you $75 for your time. Your participation is voluntary. You may stop the interview at any time. The information you provide is confidential. It will not be available to anyone else [Procedures]. No names or identifying information will appear on the interview form. Materials with personal information, such as names and addresses, will be stored in a locked room. Only NORC project staff can get to this information. Your name or other personal facts that would identify you will not be used when we talk or write about this study [Privacy].

No physical harm will come to you as a result of being interviewed. You may find some questions sensitive [Risks]. You may choose not to answer any question. If you do not want to answer a question, please tell me. I will move on to the next one. You may want to be interviewed somewhere other than your house. I will give you names and telephone numbers of helpful organizations in this area if you would like help after we complete the interview [Procedures]. If you have any questions about the project, you may call the NORC project director, Angela DeBello, at (312) 759-4069. You also can reach her by mail at NORC, 55 East Monroe, Chicago, IL 60603.

Everything you tell me will be kept private. You do not have to tell us anything you do not want to. You can choose not to answer any question I ask. You may stop the interview at any time. We still will give you the full $75 [Privacy]. There will be no other benefits to you as a result of this interview. However, results of this study will help us understand minority women’s experiences with violence and sexual violence. Also, study results will allow us to develop materials to help women who have experienced violent acts [Benefits].

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Participant Signature Print name Date

The Public Health Service Act provides us with the authority to do this research (42 United States Code 242K) and requires us to hold everything you tell us in strict confidence (42 United States Code 242m(d)). In addition, the provisions of the Privacy Act of 1974 (5 United States Code 552a) and the Confidential Information Protection and Statistical Efficiency Act (PL 107-347) apply, with the latter providing for a felony conviction and/or a fine of up to $250,000 if we violate this promise.