Form Approval
OMB No. 0925-0585-04
Expires 02/28/2011
About This Project
We have asked you to complete a short interview. It will take no more than 15 more minutes of your time to complete.
The interview will be about HIV vaccine research educational materials.
A trained person will lead the interview.
Your responses will be entered into a database and will only be seen by researchers associated with this project. Your answers will not be connected to you and you will not be asked to share your name. There will be no risk to you. You do not have to answer questions that you don’t want to. You may stop at any time. We will keep what you say private unless we are required by law to disclose it.
The National Institute of Allergy and Infectious Diseases, which is part of the National Institutes of Health, is the sponsor of this project.
You will receive $[Amount] after completing the survey.
If you have any questions, please contact Elyse Levine at [email protected]. You may ask her about your rights as a project participant or you think you have been harmed by the survey.
Thank
you for your time!
Public reporting burden for this collection of information is estimated to average 20 minutes per response. This time includes the length of time allotted for the intercept interview. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN; PRA (0925-0585). Do not return the completed form to this address.
Participant Consent
My signature confirms that I have read the “About This Project” page. I understand my rights as a participant. I agree to take part in today’s discussion. I understand that the interview is about HIV vaccine research educational materials. I realize that only the people working on this project will see the database.
I understand that my name will NOT be used in the report or any other products. No other information that could identify me will be used either.
Signature: ________________________________________________________
Name (Please print): ________________________________________________
Date: ___________________________
| File Type | application/msword |
| File Title | Informed Consent Grade Level 7 |
| Author | elevine |
| Last Modified By | Bonny Bloodgood |
| File Modified | 2009-06-29 |
| File Created | 2009-03-18 |