Survey Consent -Testing in Rural Black Men

“HIV Testing Factors Among Rural Black Men (HiTFARM)”

Attachment 2a. Survey Consent

Flesch-Kincaid Reading Level 7.4

HIV TESTING FACTORS AMONG RURAL/SMALL CITY BLACK MEN (HiTFARM)

WHY ARE YOU BEING INVITED TO TAKE PART IN THIS RESEARCH?

You are being invited to take part in a research study about HIV testing and the disclosure of HIV testing results. This consent is for the Audio-Computer-Assisted-Survey-Instrument (ACASI) part only. You are being invited to take part in this research study because you: 1) are a black male between 18 and 64 years of age who self-identifies as straight 2) live in a rural area or small city in North Florida, 3) are either HIV negative or do not know your HIV status, and 4) can speak, read, and understand English. If you volunteer to take part in this study, you will be one of about 1000 men to participate. 

WHO IS DOING THE STUDY?

The person in charge of this study is Dr. Emma Brown of CHARM, Inc. and Dr. Richard Crosby of the University of Kentucky. There may be other people on the research team assisting at different times during the study. The Centers for Disease Control and Prevention is providing financial support for this study.

WHAT IS THE PURPOSE OF THIS STUDY?

By doing this part of the study, we hope to learn more about your ideas and feelings about HIV testing. We also hope to use what we learn from you to understand the beliefs, perceptions and behaviors of men like you. Finally, we also hope to learn what you think we could do to encourage men to take part in HIV testing.

WHERE IS THE STUDY GOING TO TAKE PLACE AND HOW LONG WILL IT LAST? 

We are asking you to complete the survey at the location where you are approached. We may also ask you to return to CHARM’s outreach van. The survey will take about 45 minutes and will be done on a laptop computer with a voice to read the questions to you. The total amount of time you will be asked to volunteer for this part of the study is 45 minutes.

WHAT WILL YOU BE ASKED TO DO?

You will be asked to complete a computer-assisted survey about aspects of who you are, about your attitudes, knowledge and perceptions of HIV testing and sharing of testing results. You may both complete the survey yourself or you may ask one of the members of the research team to assist you with the computer. You will also be asked to give your name and contact information (cell phone number, home phone number, mailing address) and the names and contact information of two persons who will know your whereabouts to a member of the research team. This information will be used to contact you later about your interest in participating in a focus group at a later date.

WHAT ARE THE POSSIBLE RISKS AND DISCOMFORTS?

There are no physical risks in you completing the survey, but you may experience some minor discomfort due to the content. You may choose to skip any of the items on the survey if you are not comfortable with them.

Possible Risk/Side Effect	How often has it occurred?	How serious is it?	Can it be corrected?
Emotional discomfort	It may occur anytime during the survey	Minor	Yes

WILL YOU BENEFIT FROM TAKING PART IN THIS STUDY?

You will not get any direct benefit from taking part in this study. Your willingness to take part, however, may, in the future, help us to develop better ways to encourage men like you to be tested for HIV and talk to their sex partners about their test results.

DO YOU HAVE TO TAKE PART IN THE STUDY?

You may decide to volunteer for the study or you may decide not to volunteer. You can stop completing the survey at any time.

IF YOU DON’T WANT TO TAKE PART IN THE STUDY, ARE THERE OTHER CHOICES?

If you do not want to be in the study, there are no other choices except not to take part in the study.

WHAT WILL IT COST YOU TO PARTICIPATE?

There is no cost to you for taking part in the study.

WHO WILL SEE THE INFORMATION THAT YOU GIVE?

We won’t record your name on the survey. We will make every effort to keep anyone who is not on the research team from knowing that you gave us information, and from knowing what that information is. We will keep the laptops with the surveys in a locked file cabinet in the researcher’s locked office. We will also keep your contact information in a locked file cabinet, but separate from the surveys.

CAN YOUR TAKING PART IN THE STUDY END EARLY?

You can decide to not continue with the survey at any point if you do not feel comfortable. You will not be treated differently if you decide to stop taking part in the study at any time.

PARTICIPATION IN OTHER RESEARCH STUDIES

You may take part in this study if you are currently involved in another research study.

WHAT HAPPENS IF YOU GET HURT DURING THE STUDY?

If you believe you are hurt because of something that happens while taking this survey, you should call Dr. Emma J. Brown at 386-754-0102 immediately.

WILL YOU RECEIVE ANY REWARDS FOR TAKING PART IN THIS STUDY?

As a token of appreciation, you will receive $10 for a complete survey and $5 for an incomplete survey.

WHAT IF YOU HAVE QUESTIONS, SUGGESTIONS, CONCERNS, OR COMPLAINTS?

Before you decide whether to accept this invitation to take part in the study, please ask any questions that might come to mind now. Later, if you have questions, suggestions, concerns, or complaints about the study, you can contact the investigator, Dr. Brown at 386-754-0102. If you have any questions about your rights as a volunteer in this research, contact the staff in the Office of Research Integrity at the University of Kentucky at tolls free at 1-866-400-9428. We will give you a signed copy of this consent form to take with you.

WHAT IF NEW INFORMATION IS LEARNED DURING THE STUDY THAT MIGHT AFFECT YOUR DECISION TO PARTICIPATE?

If the researcher learns of new information in regards to this study, and it might change your willingness to stay in this study, the information will be provided to you. You may be asked to sign a new informed consent form if the information is provided to you after you have joined the study.

WHAT ELSE DO YOU NEED TO KNOW?

The Centers for Disease Control and Prevention is providing financial support for this study.

Agreement to Participate

By signing this consent form you agree that you have read this form or had it read to you. You agree to answer questions as best as you can. You also agree that you have been given a copy of the consent form and you agree to be in the study.

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Signature of person agreeing to take part in the study Date

 

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Printed name of person agreeing to take part in the study

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Name of [authorized] person obtaining informed consent Date

 

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Signature of Investigator