Form no number no number Consent questionnaire

Attachment 3b

Multi-Site HIV Testing in Mental Health Settings: Consent Questionnaire

February 3, 2021

Form approved

OMB no. 0920-xxxx

Expiration date xx/xx/20xx

Multi-Site HIV Testing in Mental Health Settings: Consent Questions to Assess Comprehension

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. CDC may not conduct or sponsor, and a person is not required to respond to a collection of information unless a currently valid OMB control is displayed. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC Information Collections Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (XXXXXXXX).

INTERVIEWER: ASK THESE QUESTIONS OF ALL PARTICIPANTS AFTER REVIEWING THE INFORMED CONSENT FORM BUT PRIOR TO SIGNING IT.

Now I’m going to ask you a few questions about the consent form to make sure that everything I

described was clear.

1. The purpose of this study is to better understand:

1. How medications work

2. Find out more about offering rapid testing for HIV.

3. How people get along with their family members

2. If I agree to participate, I am agreeing to:

   1. Get tested for HIV and complete an interview

   2. Participate in five interviews

   3. Participate in an in-depth interview

3. I can refuse to answer any questions that make me feel uncomfortable.

   1. True

   2. False

4. If I agree to participate my treatment may be affected

   1. True

   2. False

5. The interview will take:

   1. 10 minutes

   2. 45 minutes

   3. Four hours

6. I know that I can withdraw at any time without penalty

   1. True

   2. False

7. I know that a positive HIV test will result in my name being reported to the Health Department

   1. True

   2. False

SCORING:

Question Number	Correct Initially? (Y/N)	Number of times re-explained? (0-2) **	Competent? (Y/N) **
1
2
3
4
5
6
7
** Interviewer: If on any question the content is re-explained two (2) times and the respondent still does not answer correctly then the respondent is incompetent to proceed and should not be interviewed at this time.

______________________ ___________________

Signature of Staff Member Date

1