0920-New_att4_Participation Agreement

“Community-based Organization (CBO) Monitoring and Evaluation
Project of WILLOW (CMEP-WILLOW)”

Attachment 4
Participation Agreement

Community-based Organization (CBO)
Monitoring and Evaluation Project of
WILLOW (CMEP-WILLOW)
Participation Agreement Form
Purpose, Participation and Procedures
CMEP-WILLOW is an evaluation project funded by the Centers for Disease Control and
Prevention (CDC) to look at (1) how WILLOW is delivered at Agency name and (2) changes in
your self-reported sexual behaviors and attitudes after participating. The findings may help
Agency name improve the way they deliver WILLOW and better serve their clients.
To be eligible to participate in CMEP-WILLOW, you must:
1) be female;
2) be 18 years of age or older;
3) be living with HIV; and
4) have been diagnosed with HIV infection at least 6 months ago
As part of CMEP-WILLOW, you are expected to participate in WILLOW and complete
three interviews. The interviews will take place before WILLOW starts and again 3 and 6 months
after WILLOW is finished. During these interviews, you will be asked questions about your
background (e.g., year of birth, race, etc.), attitudes about HIV, and drug and sex behaviors.
Your responses from all three interviews will be compared to see if there are changes in your
attitudes and behaviors.
Risks and Discomfort
The questions asked during the interviews are very personal. To help keep your
responses private, each interview may be given to you electronically through a computer or
hand-held device. If you prefer, a face-to-face interviews may be done instead with a staff
member using the computer to answer the questions. As a voluntary participant, you do not
have to respond to any question you do not want to answer and can stop an interview at any
time.
Benefits
There is no direct benefit to you for being in this project. However, the information
from this project may help improve WILLOW at this agency.
Disclosure of Alternative Treatment
Your participation in this project is voluntary. If you do not want to participate in this
project, you are still eligible to participate in WILLOW and other services provided by Agency
name.

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Confidentiality
The information collected during the interviews is very personal and sensitive in nature.
To protect your confidentiality, the staff at Agency name will:
 Implement strict CDC security requirements, including the Health Insurance Portability
and Accountability Act (HIPAA) Privacy Rule to ensure security of the data collection
system and the confidentiality of all client information.
 Work with CDC to maintain client confidentiality and security standards throughout the
project.
 Store hard copies of electronic files in a locked file cabinet, inside a locked room where
the data will be kept secure and organized to ensure confidentiality. Project data will
not contain any information to identify a client. In other words, your name will not be
connected to your answers to any questions.
 Encrypt data before sending to CDC.
 Submit data to CDC via the Secure Data Network (SDN).
Once electronic data are received by CDC, they will be reviewed for completeness and
errors and stored securely.
Compensation
Agency will need to insert information about the token of appreciation that participants will
receive here.

Contact Information
Agency will need to insert contact information for CMEP agency staff here.

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Agreement Statement and Signature
Your participation in this project is voluntary. In other words, you decide if you want to be in
this project or not. If you agree to participate in this project and later decide that you no longer
want to participate, you can withdraw at that time.
The staff explained the point of the project, the time needed, and the tokens of appreciation
that will be given to be in the project.
I agree to be in the evaluation project CMEP-WILLOW.
___________________________________________
CMEP Participant

___________________
Date

___________________________________________
CMEP Representative

___________________
Date

I decline to be in the evaluation project CMEP-WILLOW.

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