Attachment A - Consent form

ATTACHMENT A

PREP MULTI-COMPONENT EVALUATION

DESIGN SURVEY

CONSENT FORM

FOR AUDIO RECORDING OF INTERVIEWS

PERSONAL RESPONSIBILITY EDUCATION PROGRAM (PREP) EVALUATION

PREP DESIGN SURVEY

CONSENT FORM FOR RECORDING OF INTERVIEW

PERSONAL RESPONSIBILITY EDUCATION PROGRAM EVALUATION

The Patient Protection and Affordable Care Act (often called “health care reform”), signed into law in March of 2010, established the new federal Personal Responsibility Education Program (PREP). Among other activities, this program provides funds to states for programs designed to educate adolescents on both abstinence and contraception for the prevention of pregnancy and sexually transmitted infections, including HIV/AIDS, and at least three adulthood preparation subjects. (Many states choose to provide sub-awards within their states.) An evaluation is being carried out by [INSERT NAME OF CONTRACTOR] to assess the many different facets of this program.

PREP DESIGN SURVEY

As part of the evaluation, [INSERT NAME OF CONTRACTOR] is interested in learning more about how PREP-funded programs were designed. Among many items, we are interested in how program and policy decisions were made at the State and organizational levels, the context in which States and organizations are operating, the relationship between the States and sub-awardees, and other information. This information is being collected primarily through interviews with individuals involved in PREP, either at the State or sub-awardee level.

SELECTION OF DESIGN SURVEY PARTICIPANTS

You are involved in a program which receives federal PREP funding, either as part of the state agency receiving the federal funds or as a member of a sub-awardee organization receiving funding. Due to your involvement in the program, you have been recruited to offer your insight into the program.

DESCRIPTION OF INTERVIEW AND VOLUNTARY PARTICIPATION

Interviews for this survey will likely last around one hour and will follow a conversational question-and-answer pattern. Honest, frank responses are encouraged – although answers to all questions are completely voluntary. If you don’t want to participate, that is okay. If you don’t want to answer a certain question, that is also okay. Your refusal to participate in the interview or to answer any question will not affect any funds that you or your agency may be receiving. You have the right to take a break from, or leave, the interview at any time.

PURPOSE OF CONSENT FORM: AUDIO RECORDING

We will be making audio recordings of interviews when consent is provided; thus, the purpose of this consent form is for you to offer voluntary consent for the interview to be audio recorded, should you choose. The recordings will be reviewed by project staff at [CONTRACTOR’S NAME AND SITE]. The recordings will only be used for review, and will be kept confidential. The files will be destroyed after they have been reviewed. If you do not wish for your interview to be recorded, you will still be able to participate in the interview and offer your insights, and the interview will not be audio-recorded.

RISKS

There are no risks to you from participating in the interview.

BENEFITS

There are no direct benefits to you from answering the interview questions. However, you will be helping us learn more about programs geared toward preventing teen pregnancy and sexually transmitted infections, and ultimately about what types of programs may be effective.

CONFIDENTIALITY

The interview will not be confidential, but your name and affiliation will not be linked to the answers you provide. Rather, the information you and others provide will be combined to show summary information across PREP-funded programs. Furthermore, to the fullest extent allowable by law, information identifying you will not be provided publicly.

QUESTIONS

If you have any questions about the study, you may call [ENTER CONTRACTOR INFORMATION].

You will be given a copy of this consent form to keep.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection unless it displays a valid OMB control number. The valid OMB control number for this information collection is [ENTER INFORMATION]. The time required to complete the interview is estimated to be one hour.

The above information has been explained to me, and my signature below indicates that I give consent for my interview to be audio recorded.

Printed Name of Participant		Signature of Participant		Date