Revised Informed Consent form

INFORMED CONSENT FORM

Pilot Site #2

Violence Against Indian Women (VAIW) Pilot Study

Purpose of the Study

We would like to invite you to participate in Violence Against Indian Women (VAIW) pilot research study. The purpose of this pilot study is to develop a survey process for a nationwide study to better understand health and safety issues for American Indian women living on tribal land. A pilot study is a small research study that helps ensure that a proposed national survey will be culturally and community appropriate, will be respectful of those who will participate in the study, and that the information collected will be relevant and helpful. RTI International, a not-for-profit research organization, is conducting the pilot study with funding from the United States Department of Justice’s (DOJ) National Institute of Justice (NIJ). This funding was provided at the request of American Indian people and grassroots organizations concerned about the health and safety of American Indian and Alaska Native women. With the approval of your tribal leadership, your community has been selected to pilot test the survey and the methods for selecting survey participants.

Participants

We are asking you to participate because you are one of 140 women randomly selected from a list of women living in [INSERT LOCATION] who are at least 18 years of age.

Procedures

If you agree to participate in this study, we will ask you to complete a survey on women’s health and safety. This survey asks your opinions about safety issues in your community, the kinds of support available to you, your experiences with physical and sexual violence, and your opinions about the police, courts, prosecutors, and service providers in your community.

• I will read the first set of questions from a computer screen and type your answers into the computer.

• The second set of questions is personal and you will complete those questions on your own using the computer. For the personal questions, I will show you how to use the computer and headphones. Then you will be able to read the questions on the computer screen while you listen to them through headphones. You will then enter your answers directly into the computer by touching the screen. I will be nearby but I will not look at the screen while you are answering the questions.

• When you are done answering the more personal questions, I will complete the interview by asking you the final set of questions.

We expect that the average interview will take about an hour, but the amount of time it takes you will depend on your experiences.

Voluntary Participation

Your participation in this study is completely voluntary. You may refuse to participate in this study or in any part of this study. While we hope you will agree and that you will complete the entire interview, you can refuse to answer any of the questions. Your refusal will not affect any services you may be receiving. You also have the right to stop the interview at any time. If you want to stop the study, just tell the interviewer you want to stop. You do not have to say why. We encourage you to ask questions about this study at the beginning or any time during the research study if there is something you don’t understand.

Expected Benefits of Study Participation

There are no direct benefits to you from participating in this study. However, by participating, you will help us be sure we are using a good survey instrument and a respectful process that will help us learn more about the experiences and needs of American Indian women when the national study is conducted.

Risks of Study Participation

There are risks involved in all research. We think this study includes only minimal risks. One of the possible risks with this study is there are questions of a personal nature which you may find upsetting or distressing. If you are upset or uncomfortable you may skip questions, or you may stop the interview at any time.

Confidentiality

All information gathered in this study will be kept completely confidential. Your name will be used only to identify you and will not be connected to the answers that you provide. No one, not even me as the interviewer, will know how you answer the questions. Your answers will be combined with answers from other study participants and reported in a summary form.

The answers you enter into the computer are stored in a secure data file on the computer that is password protected. Interviewers are not able to see the answers you enter while you are completing the interview on your own. The data files are sent to RTI’s home office each night during a secure data file transfer process. No identifying information (like your name) is recorded in the data file. The only people who are allowed to see the data are those who are analyzing it. The data files are deleted from the laptop at the end of the study.

DOJ policy provides for the protection of the privacy and well being of individuals who are participants in NIJ research studies through the statutory protection provided to private information under the authority of 42 U.S.C. § 3789g and the other DOJ regulations on the Confidentiality of Identifiable Research and Statistical Information found in 28 CFR Part 22. All staff involved in this study is committed to confidentiality and have signed a Confidentiality Pledge.

Compensation

To thank you for your time and effort, we will give you $35 in cash for participating in this study.

Questions

If you have any questions about the study, you may call a member of the research team toll free at 800-334-8571 (ext. 2-2703) or 919-485-2703 or you can write to RTI International, VAIW Study (0212347), Building 09 Room 317, P.O. Box 12194, Research Triangle Park, North Carolina, 27709. If you have questions about your rights as a project participant, you can call RTI's Office of Research Protection toll free at 1-866-214-2043 or you can write to them at RTI International Office of Human Subject Protections, PO Box 12194, Research Triangle Park, North Carolina, 27709-2194.

I would like to go over the main points covered in this form to make sure everything is clear before you decide if you want to participate.

This interview is voluntary. You can say yes or no. It is totally up to you.

Do you understand that you do not have to do this interview? Yes No

If you start the interview and then want to quit, that is okay. While we hope you will answer every question, you may skip questions you don’t want to answer.

Do you understand that you do not have to answer every question? Yes No

It is possible that some of the questions you answer using the computer may make you feel nervous or upset. If that happens, you can tell me and we will take a break or continue at a later time.

Do you understand that some of the questions might make you uncomfortable and that you can take a break or continue the interview at a later time? Yes No

The form I just read aloud to you also talks about confidentiality. By confidential, we mean that the answers you enter into the computer yourself will always be kept private. No one will ever know your answers to those questions, not even me.

Do you understand that the answers you enter into the computer will remain confidential? Yes No

Do you have any questions?

By signing below, you are agreeing to participate in the study. Please sign only if:

• You understand the information about the study in this consent form,

• You have had all of your questions answered fully, and

• You want to participate in the study.

Respondent’s Signature: ______________________________________ Date: _________

Interviewer’s Signature: ______________________________________ Date: _________

Consent for Quality Control Recordings

I am using a special quality control system on this project. I will not use this system unless you agree. The system runs on the computer and will record portions of what you and I say to each other during several different parts of the interview. Neither you nor I will know when the computer is recording what we say. The recording will be reviewed by people at RTI to monitor my work and makes sure the interviews are going correctly. The portions of the interview that are recorded will be kept confidential. They will be used for training and quality control purposes only. The project staff who listens to the recording will know who I am, but they will not know who you are. You may participate in the interview even if you do not consent to the recordings. May we use this quality control system during your interview? If you agree to allow us to use this quality control system, please sign below.

Respondent’s Signature: ______________________________________ Date: _________

Interviewer’s Signature: ______________________________________ Date: _________