Consent for Exit Interview

Form Approved:

OMB No. 0920-xxxx

Expiration Date: xx/xx/xxxx

Attachment 14

Informed Consent for Exit Interview

Critical Thinking and Cultural Affirmation (CTCA) HIV Prevention Intervention

for African American Men who have Sex with Men (AAMSM)

Principal Investigator: Darrell P. Wheeler, Ph.D., M.P.H.

Phone Number312.915.7005

A. Purpose

You are being asked to take part in an exit interview to talk about your experience with the Critical Thinking and Cultural Affirmation program you completed. You are being asked to consent to having the interview audio recorded. Loyola University Chicago, Black Men’s Xchange, and the Centers for Disease Control and Prevention (CDC) are conducting this research. You may choose whether or not to participate in the exit interview. The information below will help you make an informed choice about whether or not to take part. We hope to learn how to improve the program.

B. What Will Happen:

If you choose to take part (consent), the following will happen:

1. At today’s visit, you will be interviewed by a member of study staff. This interview will be audio recorded. If at any point during the interview, you wish to stop, you may do so with no penalty.

2. You will receive a $50 gift card and a two-way CTA Transit Pass for your participation.

3. The audio recording will be used to make a transcript of the interview. Your responses and the responses of other men will be used to evaluate the CTCA intervention.

C. Privacy

Your research records will be kept private to the extent permitted by law. We cannot promise complete privacy. To protect your privacy, we will give you a study ID number. Your name will not be on any recorded materials, including exit interview recordings and transcripts. Personal information from your records will be locked at our study site. Your personal information will not be given to anyone, including the CDC, without your written approval.

The recordings will be kept in a locked cabinet and any digital versions, including transcripts, will be kept in a computer file that can only be opened by study staff. Only study staff with a need for this information will have access to it. The recordings and any electronic versions of the recordings will be destroyed after three years.

D. Exceptions to Privacy

Abuse of a child by a parent or someone legally responsible for a child must be reported to child welfare services. If you are 18 years or older and report physical abuse of or sexual contact with a child for whom you are legally responsible, then staff will report your name to the child welfare services.

E. Risks and Discomforts

If you experience discomfort during the interview and wish to discontinue, you may do so at any time. The interview will not be able to continue without the audio recording, but there will be no penalty to you for withdrawing your consent at any time during the interview.

F. Benefits

The potential benefits for you of taking part in this interview and having it recorded include:

1. You may gain insight about yourself and your identity.

2. You will have a chance to reflect on your experiences.

G. Costs

There will be no costs to you as a result of taking part in the exit interview and having it recorded, other than your time.

H. Tokens of Appreciation

You will receive tokens of appreciation for your time and travel. You will get a $50 gift card and a two-way CTA Transit Pass.

I. Voluntary Participation and Withdrawal Statement

Your taking part in the exit interview and having it recorded is up to you. Your choice of whether or not to take part and/or complete the interview will not interfere with your right to services to which you are otherwise entitled. You are not giving up any legal claims or rights because you are taking part in the exit interview. If you do decide to take part, you are free to take back your consent and stop taking part at any time.

J. Injury Statement

Although not likely, in the event you are harmed during the interview and need medical treatment, we will refer you to get care. We may refer you to a nearby hospital for emergency care (if needed) or give you a referral for other medical care. However, Loyola University, Black Men’s Xchange, and the Centers for Disease Control and Prevention do not pay for this treatment. Signing this form does not mean that you are giving up any legal rights to be paid for harm that results from being in this study. For more information about this, you may contact the Principal Investigator listed in this form.

K. Offer to Answer Questions

If you ever have questions or problems about this study or in case of study-related injuries, you should contact:

Darrell Wheeler, Ph.D., M.P.H. at 312.915.7005

If you have questions about your rights as a research participant, you may contact the Loyola University Office of Research Services at (773) 508-2689

You may also write the IRB office:

Dr. Andrew Ellis

820 N. Michigan Avenue

Chicago, IL 60611

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

N. Agreement

I have read (or someone has read to me) the information provided above. I have been given the chance to ask questions and all of my questions have been answered to my satisfaction. I am free not to join this study, or to stop being in this study at any point. I know that project staff may observe the program and counseling sessions and if I am selected to participate in the exit interview this interview will be audio recorded. My signature below indicates that I have chosen to take part in this research.

Please sign your name and check the boxes below if:

 you have read this consent form (or had it explained to you),

 all your questions have been answered and

 you agree to take part in the exit interview

 you agree to have the interview audio recorded.

______________________________________________________________________

Name of Study Volunteer Signature of Study Volunteer Date

______________________________________________________________________

Name of Investigator/Person Signature Date

Obtaining Informed Consent

This consent form is only valid if it carries the IRB approval stamp with current dates.