0990-Community Spirit_Attachment D

Multi-site Evaluation of the In Community Spirit Program

HIV Education, Awareness, and Lifestyle (HEAL) Survey—Prevention Education Survey Consent Form

Purpose of the Study

The Office on Women’s Health (OWH) in the United States Department of Health and Human Services is studying the In Community Spirit Program. On behalf of OWH, ICF Macro is asking that you complete this survey. The survey includes a series of questions asking you about your awareness and knowledge of HIV and its prevention as well as lifestyle choices related to sexual health. The findings from the survey will inform OWH about the impact of the In Community Spirit Program on knowledge, awareness, and behaviors related to HIV and its prevention.

Description of Participation

You were asked to participate in this survey because of your participation in a prevention education curriculum at [insert organization name]. The survey consists of XX questions and should take approximately 15 minutes for you to complete.

Here are some things we want you to know about the survey prior to agreeing and consenting to participating:

Risks and Benefits

Completing this survey poses few, if any, risks to you. Questions may make you feel uncomfortable or cause you to feel emotional. You can choose not to answer any question for any reason. You may choose to stop the survey at any time or not answer a question, for whatever reason. Your participation will not result in any direct benefits to you. However, your input will be used to help inform HIV prevention programming with AI/AN women.

Compensation

You will receive $5 for participation in this survey.

Privacy

All responses will be treated privately. Your name and answers to these questions will be kept private. To protect your privacy, we will keep the records in locked files and only study staff will be allowed to use them. Your name will not be used in any reports about this study. Only authorized people will have access to the information you provide. The information that we report will be done in aggregate, will not contain any identifying information and your name will not be used in any reports about this evaluation.

Rights Regarding Decision to Participate

Participation in the survey is completely voluntary. Refusal to participate involves no penalty or adverse consequences. You do not have to answer questions that you do not want to answer. You may choose to discontinue the survey at any time, for any reason.

Contact information

If you have any concerns about your participation in this survey or have any questions about the evaluation, please contact Robin Davis @ [email protected] or you may call her at 404-592-2188.

Voluntary Consent

By signing your name below, you are confirming that 1) you have read this form or, it has been read to you, 2) that you understand what it says and 3) all of your questions have been answered. By signing your name below you freely agree to take part in the survey. A copy of the form will be provided to you.

Do you agree to participate in this survey?

• YES

• NO

Please print your name
Please sign your name
Date

THANK YOU

Multi-site Evaluation of the In Community Spirit Program HEAL Survey—Prevention Education Consent