Consent Form

ATTACHMENT H

Consent Form

CDC/NYVPRC Evalaution STUDY consent form

BACKGROUND AND PURPOSE OF THE RESEARCH

SRA is a health research organization and we have been contracted by the Centers for Disease Control’s (CDC) National Youth Violence Prevention Resource Center (NYVPRC) to evaluate pilot users of the revised website.

As part of this evaluation you will be asked to participate in a Coalition Leader interview and/or Coalition Member survey so that we can better understand your experiences with the website and how we may improve the website and its functionalities for future uses.

PROCEDURES

• If you are a coalition leader, you will be asked to participate in a one hour interview both at 6-months and 12 months after you have joined the pilot project.

• If you are a coalition member, you will be asked to participate in a thirty minute survey both as 6-months and 12 months after you have joined the project.

• Any questions you have about this project can be answered before participating in the survey or interview.

• You are not required to answer any questions you do not want to.

• Only project staff will have access to the information provided in either the interviews or surveys. Project staff will have access to this information because they will write a report to summarize the findings of the interviews or surveys.

• Interviews will be audio recorded and notes from the tapes will be made. Later, other people working on the project may listen to the tapes or read the notes because they cannot be here in person.

• There will not be any experimental procedures conducted during the research.

• Your participation is secure and no information that can personally identify you will be included in any reports.

RISKS/BENEFITS

There should not be any risks, either physical or mental, to you by taking part in this project. You will be asked to share your opinions about your experiences on the website and in the coalitions in which you participate.

COMPENSATION (PAYMENT)

There will be no compensation for participation in this project.

PRIVACY

To protect your privacy, all tapes, notes and survey data will be stored in a secure, private place. Only people working on this project will be allowed to read the notes, listen to the tapes or access the data.

Everything that you say or report will be kept private, as allowed by law. Your name will not be used in any reports about this group.

RIGHT TO REFUSE OR LEAVE

Your taking part in the interviews or surveys is totally voluntary. You may choose to discontinue participation in the interview or survey at any time. You do not have to answer any question that you do not wish to answer. This will not affect your standing in the project.

PERSONS TO CONTACT

If you have questions about your rights as a research participant, please contact the CDC Human Research Protection Office at 1-800-584-8814. Leave a brief message with the protocol number, protocol #****, your name, and phone number, and you will be called back as soon as possible.

CONSENT

I agree to take part in the interviews and/or surveys. I have read this consent form. I have been given a chance to ask questions and I feel that all of my questions have been answered. I understand that this study will evaluate the NYVPRC website and our personal experiences within the coalition in order to better help government and community leaders to become involved in youth violence prevention. I consent to being audio recorded. I understand that only staff working on this project will be able to have access to the survey data, listen to the tapes, or read the notes. I know that I may leave at any time.

IF WRITTEN:

Participant’s Signature: __________________________________

Date: ________________

Participant’s Name (Please Print): ___________________________________________

IF VERBAL:

Do I have your consent to continue with the interview?