Attach2a_Eligibility_Screener_Consent[1]

Evaluation of Rapid HIV Self-Testing: Qualitative and User Proficiency Assessments

Generic Information Collection Request under 0920-0840

Attachment 2a

Eligibility Screener Consent Form

Emory University, Rollins School of Public Health

Consent to be a Research Subject

Title: Evaluation of Rapid HIV Self-Testing: Qualitative and User Proficiency Assessments

Principal Investigator: Patrick Sullivan, DVM PhD

Funding Sources: Emory University, Centers for Disease Control and Prevention (CDC), MANILA Consulting Group, Inc.

Purpose: The Emory University Rollins School of Public Health is doing a research study of men who use the Internet. The purpose of this study is to learn about behaviors that put people at risk for getting diseases transmitted by having sex (like HIV). The information we learn from this study will help create better HIV prevention programs for people in our community.

Procedures:  If you would like to be in the study, you will take a 5 minute Internet survey to see if you are eligible. All of your answers to the survey questions will be private.

In the survey you will be asked questions about the following topics:

a. Your age, race/ethnicity and gender

b. Your sex behavior

c. If you have ever tested for HIV

d. Your contact information

You will take this survey on a computer. The web site where the survey is located is secure and any answers you give us will be safely stored on a password-protected computer. Researchers will not be able to link your responses to you or your Facebook page. You can refuse to answer a question at any time. If you don’t answer a question, or if you want to end the survey, there will be no penalty to you.

Based on your responses to this survey, you may be asked to participate in a research study. If you are asked and agree to participate in the study, we will ask that you provide additional information.

Risks and Discomforts: All of your answers will remain private. Some of the questions in the survey are about sex and may make you feel uncomfortable. Your participation is completely voluntary and you can refuse to answer a question at any time.

Benefits:  There are no direct benefits by taking this survey. The information from the Internet survey may be used to determine eligibility for a research study.

Compensation: If you agree to take this survey, you will not receive any compensation (money or otherwise) for taking this survey.

Privacy:  The contact information you give us will be kept in a secure location and will not identify you. If you are eligible to participate this information will be used to contact you to make an appointment for the research study, then it will be destroyed. The survey answers you give us will be grouped with survey answers from other persons. Researchers will not be able to link your responses to you or your Facebook page. If you are asked and agree to participate in the research study, you will be asked to provide additional information. You do not have to participate in the study and you can still participate in this survey even if you do not want to provide additional information for the research study.
 

Voluntary Participation and Withdrawal

Being in this research is voluntary and you have the right to refuse to answer all questions in the survey. You can stop at any time after giving your consent.

Contact Persons

If you have any questions about this study or feel you have been harmed in this study please contact a member of the research team:

Patrick Sullivan, DVM PhD

Emory University

Rollins School of Public Health

1518 Clifton Road NE

Room 464

Atlanta, GA 30322

(404) 727-2038

If you have any questions about your rights as a participant in this study or feel you have been harmed by being in this study you can contact the institutional review board at Emory University.

For Emory University contact:

Emory IRB

1599 Clifton Road

5th Floor East

Atlanta, GA 30322 USA

Tel: 404 712 0720

Toll free: 877 503 9797

Email:[email protected]

You may print a copy of this form for your records if you like.

If you agree to the above and would like to participate in this study, please click “Agree” below.

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