Assessment of QDS System - consent forms

Assessment of a QDS Data Collection System in HIV Prevention

Program Evaluation

#0920-0840

Expiration date: 31 January 2013

ATTACHMENT 2

Consent Forms

Assessment of a QDS Data Collection System in HIV Prevention Program Evaluation

#0920-0840

Consent Forms

Monitoring and Evaluation of MPowerment (MEM)

Client’s Consent to Participate

Explanation:

The Monitoring and Evaluation of MPowerment (MEM) Project is funded by the Centers for Disease Control and Prevention and is offered in conjunction with In The Mix. The purpose of MEM is to evaluate client participation with In The Mix, which is a social and educational group for young gay men of color focused on improving community norms for HIV and STD prevention and awareness in San Diego.

Consent:

I understand that my participation in MEM is completely voluntary and that I can withdraw at any point given written or verbal notification to MEM Project staff.

I understand that my participation in MEM will involve regular attendance and participation in programs and activities offered by In The Mix.

I understand that my participation in MEM will involve the completion of three questionnaires administered upon enrollment, after 90 days of involvement and attendance at In The Mix programs and activities, and after 90 days of In The Mix program closure.

I understand that data, which will be collected, will be kept secure to the maximum extent permitted by law,is private and that I will be not be identified by name in any statistical reporting.

I therefore agree that I have been informed regarding my involvement with MEM and give my consent to participate in the program.

__________________________________ _______________

Participant Signature Date

__________________________________ _______________

MEM Project Staff Signature Date

AID ATLANTA, INC.

DEPARTMENT OF EDUCATION AND VOLUNTEER SERVICES

PATIENT ACKNOWLEDGEMENT OF NOTICE OF PRIVACY STATEMENT

Our Legal Duty: We have a duty to protect the security of medical information about you. We are required to provide you with a Notice of Privacy Practices explaining ways we may use and disclose your medical information. The Notice also describes your legal rights and our obligations regarding the use and disclosure of your medical information.

Parties Following The Notice: The Notice will be followed by the Department of Education and Volunteer Services of AID Atlanta, Inc. and its affiliates, together with their health care professionals, staff and volunteers; and other legal entities that provide services to the Department of Education and Volunteer Services.

How We May Use and Disclose Medical Information About You: We may use or disclose identifiable health information about you for many reasons, including:

● Treatment ● Activities of managed care networks in which we participate

● Payment ● Activities of our affiliates

● Health care operations ● Appointment reminders

● Health oversight activities ● Fundraising activities

● Public health purposes ● Organ donation

● Auditing ● To avert a serious threat to health or safety
● National security and protective services ● To coroners, medical examiners and funeral
● Research directors
● Workers’ compensation ● To military command authorities

● Lawsuits and disputes ● As required by law

● Law enforcement purposes ● For federal or state reporting required by grants

In general, other uses and disclosures of your medical information will require your written authorization. We may use or disclose certain limited information about you, unless you object or request a limitation of the disclosure, for:

● Individuals involved in your care or payment

Your Privacy Rights:

You have the following rights with respect to your health information:

● The right to request private, secure communications and alternative means of communication with you.

● The right to request restrictions on certain uses of your health information.

● The right to inspect and copy certain medical information that we maintain about you.

● The right to request an amendment of your health information.

● The right to an accounting of certain disclosures of your health information.

Changes to the Notice: We reserve the right to change the Notice. We will post any revised Notice in the Department of Education and Volunteer Services.

Complaints: If you believe your rights have been violated, you may file a complaint with the EDVS CQI Manager at (404) 870-7742 or you may file a written complaint with the Secretary of the U.S. Department of Health and Human Services.

ACKNOWLEDGMENT

Patient Name:

Patient Acknowledgment: I acknowledge that I have received a copy of the Notice of Privacy Practices for AID Atlanta’s Department of Education and Volunteer Services. In receiving the Notice, I also acknowledge that I have been provided with an opportunity to ask questions regarding the Notice and its contents.

Signature of Patient: Date: ___________

For Use by DEDVS Personnel Only: [Complete if patient acknowledgment is not obtained]

The patient was provided with a copy of the Notice of Privacy Practices and a good faith attempt was made to obtain the patient’s signature acknowledging receipt of the Notice. An acknowledgment was not obtained because ____________________________.

Signature of DEDVS Representative/Case Manager: Date: ____________

a program of CALOR, a Division of Anixter Center

CONSENT TO PARTICIPATE IN THE PROGRAM

I, _____________________________________, consent to participate in Unidad, a Prevention program which uses the MPowerment DEBI (Diffusion of Effective Behavioral Interventions) as a method to educate young Latino men that have sex with other men on the prevention of HIV/AIDS through safer sex and risk reduction practices. It aims to disseminate this prevention message by empowering the young participants to share the prevention message with their peers in their social networks. Unidad is funded through a federal grant provided by the Centers for Disease Control and Prevention.

By providing my consent, I confirm that I understand and agree to the following:

• Participation is voluntary.

• The weekly social and educational groups are an adaptation to the original model, implemented based on the expressed needs of participants. During this groups, a variety of contemporary topics are discussed with the purpose of providing informational and educational material to the participants, and to provide them with a forum where they can express and share their points of views.

• All the information shared during the group sessions will be kept private and will not be shared with anyone outside of the group setting.

• There are two sessions of the social and educational groups: one conducted in Spanish, and one conducted in English. In order to maintain fidelity in participation numbers, I have to choose to become a participant in only one of the two sessions. Once I pledge participation to one of the sessions, I am welcomed to participate in the other session as a guest only.

• Another component of the program is the Core Group. The Core Group is composed of 4 participants who share the responsibility of organizing the activities of the group, as explained in the document Core Group Duties. I understand that I can receive incentives for becoming a Core Group member and fulfilling my responsibilities as out lined in the above-referenced document.

This consent is valid for a period of one year from the date of the actual client signature below.

I pledge participation to the English Spanish social and educational group.

___________________________________________ ____________________________________

Signature of Client or Client’s Legal Representative Date

___________________________________________ ____________________________________

Print Name Relationship (if signed by person other than client)

___________________________________________

Witness

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