Message Testing - Interview Consent

Development of HIV Prevention Decision Support Messages

for Men Who Have Sex with Men and Heterosexuals

Consent Form/ Qualitative Interview

Reading Level 7.2 (Assessed By Flesch-Kincaid)

Introduction and Purpose:

You have been asked to take part in an in-depth interview as part of a research study. The purpose of the interview is to hear your opinions about health related topics. RTI, a non-profit research organization is conducting the interview. The interview is sponsored by the Centers for Disease Control and Prevention (CDC).

Procedures:

During the interview, we will ask you to talk a little bit about yourself and what you think and feel about safer sex messages. The interview will take about 1 hour. The person leading the interview will take notes. Someone from the CDC may be observing the interview, but will not ask you any questions or participate in the discussion.

We will be doing interviews with people in Memphis, TN; Baton Rouge, LA; Detroit, MI; Philadelphia, PA; Houston, TX; Newark, NJ; Jacksonville or Miami, FL; Cleveland, OH; Charlotte, NC; Richmond, VA; Chicago, IL; Birmingham, AL; Oakland, CA; Los Angeles, CA; or Washington, DC. About 120 people will take part in the interviews.

Risk/Discomforts:

You might feel embarrassed or upset by the things that are talked about during the interview. If that happens, we will refer you to someone who can talk with you about your concerns. You can decline to talk about any topic for any reason. You can stop being in the interview at any time.

Benefits:

There is no direct benefit to you for being in this interview. However, you may learn more about how to protect your health in your relationships. What we learn from the interview will help us to develop materials about safer sex practices.

Confidentiality:

We will be audio-taping the interview. Tapes will be kept in a locked cabinet. They will be destroyed at the end of the project. Notes will be made of the tapes. We will only refer to first names in the notes. Your comments will be kept private to the extent allowable by law. The notes will be kept on a password-protected computer. Only authorized project staff will be able to see them. Any forms related to the project that have your name or information that could identify you will be kept in a locked file cabinet. These forms will be destroyed at the end of the project. However, there is still a small risk that your privacy could be broken.

Also, any information that this local facility already has about you—because you have been in other projects—will still be kept there. You may be contacted by them to be in other projects in the future. If you have not been contacted by this facility before this project, it will not keep any of your contact information.

Payment:

We will give you $50 as a token of appreciation.

Right to Refuse or Withdraw:

It is your choice to do this interview. You can choose not to talk about any topic. You can stop being in the interview at any time.

Persons to Contact:

If you have questions about the interview, you can call Jennifer Uhrig at 1-800-334-8571, extension 3311. She can be reached between 9 AM and 5 PM, Eastern Standard Time, Monday–Friday. If you have questions about your rights as a participant, you can call RTI’s Office of Research Protection toll-free at 1-866-214-2043.

Your Consent:

I have read this consent form. I had a chance to ask questions and my questions were answered. I was given a copy of this consent form. I agree to be in the interview.

First Name Only

Date

Interviewer Signature

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