0920-09CJ_att4b_Phase2 Quantitative Survey Consent

“Promoting HIV Testing among Low Income Heterosexual Young Adult Black Men”

0920-XXXX

Attachment 4b. Phase Two Quantitative Survey Consent

Form Approved

OMB No. 0920-XXXX

Expiration Date XX/XX/XXXX

“Promoting HIV Testing among Low Income Heterosexual Young Adult Black Men”

Phase Two Quantitative Survey Consent

Public reporting burden of this collection of information is estimated to average 5 minutes per response,, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-XXXX)

BEATS Project Phase Two

Consent to Participate in a Research Study

Reading Level: 7.6

We want to learn about issues young Black men who have been recently arrested or in jail face. We are hoping this information you give us will help us to develop better health programs.

This study is funded by the Centers for Disease Control and Prevention and will be lead by Dr. Scyatta Wallace, Department of Psychology, College of Liberal Arts and Sciences, St. John’s University.

If you agree to be in the study, we will ask you to complete a survey. You will be asked about your arrest/incarceration and what life has been like since being released. We would like to know your feelings about your racial and ethnic identity, and dating/relationships, including any sexual experiences you have had. We will ask you about getting health care services, such as checkups and tests for things like high blood pressure, and sexually transmitted infections such as HIV. We want to hear your ideas for health programs for Black men like you to help us develop better health programs.

The survey will take 30 minutes.

There is little risk for doing this survey. You may be uncomfortable discussing topics such as sexual relationships and life since your release

When you are done, you will get a list of health services and information about health for young Black men like you.

Your name or anything that can identify you will not be on the survey. The survey will be given a code number. All contact information will be destroyed after the survey is complete. All data will be kept in a locked file cabinet in Dr. Wallace’s private office. Consent forms will be kept in a locked file separate from the data. No research materials will be kept at Fortune Society. Interview notes will be stored in a locked safe away from the signed consent forms. The staff at Fortune Society and your parole/probation officer will not have access to this information.

Your participation in the study is voluntary. You can say no or withdraw at anytime. If you do not feel like answering certain questions, you can skip them. Not taking part in the survey or stopping early will not affect the services you receive at Fortune Society or your probation/parole status.

For taking part you will be reimbursed with a $25 gift card. If you stop before the end of the study, you will not be compensated.

Contact Dr.Wallace if you are unsure about the study or have any questions.

The contact information is: (718) 990-2398, [email protected], Department of Psychology, St. John’s University, 8000 Utopia Parkway, Jamaica, NY 11439.

If you have questions about your rights as a research participant, contact the Human Subjects Review Board at St. John’s University. The number is (718) 990-1440.

Agreement to Participate

By signing this consent form you agree that you have read this form or had it read to you. You agree to answer questions as best as you can. You also agree that you have been given a copy of the consent form and you agree to be in the study.

Research Participant’s Name:

Research Participant’s Signature:

Date:_______________________________________