Consent for Partner Services Concept Testing Interview

Form Approved

OMB No. 0920-0775

Expiration Date 04/30/2011

One-on-One Interviews

Formative Research to Develop Social Marketing Campaigns- Routine HIV Testing for Emergency Medicine Physicians, Prevention Is Care, and Partner Services

Reading level 7.3 (assessed by Flesch-Kincaid)

Introduction and Purpose:

You have been asked to take part in a research study. The purpose of the research is to conduct one on one interviews to get your reactions to materials that are being developed. The materials are for health care providers who deliver care to people with HIV. RTI International, a non-profit company in North Carolina is conducting the interview. The interview is sponsored by the Centers for Disease Control and Prevention (CDC).

Procedures:

During the interview, we will ask you to review draft materials and provide feedback. The interview will take about an hour.

We will be doing interviews with physicians in 6 cities. About 174 physicians will take part in the interviews.

The person doing the interview will take notes. CDC staff working on this project may observe the interview through a one-way mirror.

Benefits:

There is no direct benefit to you for being in this interview. However, you will be exposed to educational materials that are designed to serve as resources to share with patients and for the provider to use in their day to day practice. You may find the discussion interesting and informative. What we learn from the interview will help us to improve the materials being developed.

Risks:

The questions we ask are not meant to be sensitive. Still, there is a chance that you may feel discomfort about some of the questions we ask. You may choose not to answer any question you wish. We do not know of any other risks related to taking part in this study.

Privacy:

We will be audio-taping the interview. Tapes will be kept in a locked cabinet. Notes will be made of the tapes. We will only refer to people by their first name in the notes. Because we are not transcribing the audiotapes, we will keep the tapes for reference if needed to confirm the notes. All audiotapes will be destroyed three years after completion of the project. Your comments will be kept private to the extent allowable by law. The notes will be kept on a password-protected computer. Only authorized project staff will be able to see them. Any forms related to the project that have your name or information that could identify you will be kept in a locked file cabinet. These forms will be destroyed after the interview ends. However, there is still a small risk that your privacy could be broken.

Also, any information that this local facility already has about you -- because you have been in other projects -- will still be kept there. You may be contacted by them to be in other projects in the future. If you have not been contacted by this facility before this project, they will not keep any of your contact information.

Reimbursement:

We will give you [$150 for PCPs or $250 for IDS]as a token of appreciation.

Right to Refuse or Withdraw:

It is your choice to take part in this interview. You can choose not to talk about any topic. You can end the interview at any time. You can withdraw from the study for any reason at any time.

Persons to Contact:

If you have questions about the interview, you can call Dr. Jennifer Uhrig at 1-800-334-8571 extension 3311. She can be reached between 9 AM and 5 PM Eastern Standard Time Monday - Friday. If you have questions about your rights as a participant, you can call Dr. Wendy Vissher of RTI’s Office of Research Protection toll-free at 1-866-214-2043.

Your Consent:

I have read this consent form. I had a chance to ask questions and my questions were answered. I was given a copy of this consent form. I agree to be in the interview.

Signature

Date

Facilitator Signature

Attachment 5c