Consent

Usability Study of Medscape’s Technology-based Panel

Attachment 3. Questionnaire Consent

Participant Consent Form

(8.7 ASSESSED BY FLESCH-KINCAID)

Introduction and Purpose:

You have been asked to take part in a questionnaire as part of a research study. The purpose of the questionnaire is to hear your opinions about HIV testing and prevention. Medscape and RTI International are conducting the study. RTI is a non-profit research organization. The study is sponsored by the Centers for Disease Control and Prevention (CDC).

Procedures:

The questionnaire is about HIV testing and prevention and should take approximately 10 minutes to complete.

Risk/Discomforts and Right to Refuse or Withdraw:

You might feel embarrassed or upset by some questions in this questionnaire. You can decline to answer any questions for any reason. You can stop the questionnaire at any time.

Benefits:

There is no direct benefit to you for being in this study. However, you may learn more about HIV testing and prevention.

Confidentiality:

Your responses will be kept private to the extent allowable by law and will only be used for the purpose of this research. Many precautions have been taken to protect your information. Identifiable information such as names, address, and phone numbers will be kept separate from your responses and will not be included in subsequent reports, publications, or presentations. The findings from this study will be reported in summary form so that the participants cannot be identified.

Payment:

As a token of appreciation you will receive a $50.00 Visa gift card.

It is your choice to complete the questionnaire. You can stop taking the questionnaire at any time.

Persons to Contact:

If you have questions about the questionnaire, you can call Dr. Julia Kish Doto, Project Director, at 1-800-334-8571, extension 8280. She can be reached between 9 a.m. and 5 p.m., Eastern Standard Time, Monday through 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.

Consent:

Please choose one to continue with the questionnaire:

I have read this consent form. I agree to participate in the questionnaire.

I have read this consent form. I do not want to participate in the questionnaire.