Attachment 7a
CSBS
Model Consent Form – English
Medical Monitoring Project Demonstration Activity
Statement of Informed Consent
The following statement must be read to all potential participants:
You have been selected participate in this project because you have HIV. Participation in this project is voluntary. You choose to participate or not to participate. You do not have to be in the project if you do not want to be. You may leave the project at any time. Leaving the project will not result in any penalty or loss of benefits to which you are entitled.
Why we are doing this project
HIV is the virus that causes AIDS. Your health department, together with the Centers for Disease Control and Prevention (CDC), is doing this project to learn more about people who are infected with HIV and the types of services they use and need. This information will help us improve programs to prevent other people from getting HIV and improve services for those who already have HIV.
What we will need from you
If you choose to be in this project, we will
ask you questions.
look at your medical records.
The questions
Answering the questions will take about 45 minutes. You do not have to answer any question you do not want to answer.
The questions will ask about your
medical past
use of medical and social services
sex practices
use of drugs and alcohol
reproductive history (if you are a woman)
ability to work and take care of yourself and your family
If we need more information, a staff member may contact you later.
Although we send the answers to CDC, we do not send any information that could identify you or be traced back to you. Your answers will be kept confidential, identified only by a code number, and kept in a locked file that only project staff can open.
Your medical records
As part of routine public health surveillance, we will also look at your medical record to collect clinical information about your HIV infection. This information will include illnesses you have had, medicines you have taken, and care you have received. Again, we do not send any information to the CDC that could identify you or be traced back to you. Information from your medical records will be linked to your answers only by a code number.
What you can expect from us
Privacy
We protect your privacy. All information you give us will be kept private and confidential. Your records will be kept confidential as much as the law allows. Your answers will be grouped together with answers from other participants so that no one will know which answers came from you. We will send information from this project to CDC, but we will not send any information that could identify you. Federal law protects the confidentiality of information kept at CDC.
Payment
If you answer the questions and agree to let us review your medical records, you will receive $___ as a token of appreciation for your participation. If you later choose to leave the project, you may keep the money.
Things to consider
There is no cost to you (other than your time and effort) for participating in this project.
If you would like, we can give you information about how to avoid giving HIV to someone else.
If you would like, we can give you information about where to get medical and social services in your area.
Although you will gain no direct benefits from taking part in this project, you will help us learn more so we can improve services available to other people with HIV and AIDS.
Some of the questions may make you feel uncomfortable or may be too personal. Remember: You do not have to answer any questions you do not wish to answer.
Questions?
About this project, please
ask the person who asks you the interview questions
call (local principal investigator) at (phone number)
About your rights, please contact
The institutional review board (IRB) at (State/Local Health Department)
at (phone number).
(Local IRB contact) at (phone number)
CDC at 1-800-584-8814. This is a toll free call. Please leave a brief message including your name and phone number. Say that you are calling in reference to CDC protocol # 04155. Someone will return your call as soon as possible.
Participant’s Consent Statement
I agree to take part in the project described here. I have read the statement, understand the statement, and all my questions have been answered. I understand that my participation is completely voluntary.
_________________________________ ___________________
Signature of Participant Date
__________________________________ ___________________
Signature of Interviewer Date
CSBS May 2012
| File Type | application/msword |
| File Title | Appendix H |
| Author | DHAP |
| Last Modified By | Ptomey, Natasha (CDC/OID/NCHHSTP) (CTR) |
| File Modified | 2012-07-26 |
| File Created | 2012-07-26 |