Attachment D- RHT Consent Form

RAPID HIV TESTING COMPONENT

Consent Form for Participation in Rapid HIV Testing Activities

1. Introduction and Background

You are being asked to take part in a federal data collection effort that is a grant requirement from the Substance Abuse and Mental Health Services Administration (SAMHSA) for <INSERT GRANTEE NAME>. We are conducting rapid HIV testing along with pre and post-test counseling, and we invite you to take a rapid HIV test. If you agree, we will also complete a rapid HIV testing form.

The purpose of the rapid HIV testing is to: 1) implement and increase rapid HIV testing in various areas of the country; 2) refer individuals who test HIV-positive to treatment/medical care; and 3) enhance preventive services for those who test HIV-negative.

2. Procedures

If you agree, I will go over some pre-test information, conduct the rapid HIV test, and provide post-test information. Also, while we wait for your test results, a staff member will ask you questions from the form and record your answers on the form. The form will include questions about your background and will also ask about any previous HIV tests, your substance use, your sexual behaviors, and your test results. Your name and other information that identifies you will not be on the form and the entire process will be confidential.

If you agree, I will read each question and give you a chance to answer each question. You are free to choose whether or not you will take part in completing the form. You can choose not to answer any particular question. You can decide not to begin or to stop this form at any time. Completing the form should take 8 minutes.

3. Risks

It is possible that some of the questions may feel overly personal and make you uncomfortable. You can refuse to answer any questions or you may take a break at any time during the completion of the form.

There is a small risk of loss of privacy. However, extra measures will be taken to protect each participant’s privacy.

4. Protection of Information

The privacy of the information we collect about you will be very carefully protected. Our staff is trained on handling sensitive data and the importance of privacy. The data that is given to our funder will not include names or client identification. All forms in the project will be coded so that they cannot be associated with individual names.

5. Benefits

The benefits include knowing your HIV status and receiving pre and post-test information. If you want them, you will receive referrals to drug treatment, medical care, and prevention services. We hope that data collected as part of this effort will lead to identification and linkage to services for those who are HIV-positive.

6. Payment for participation

There is no payment for your participation.

G. Right to Refuse or Withdraw

Your participation in this data collection effort is completely voluntary and will not affect the services you receive from <INSERT GRANTEE NAME>. You may refuse to answer certain questions and you can stop answering questions at any time.

H. Persons to Contact

If you have any questions about this test or completing the form, please contact <NAME> at <GRANTEE NAME>.

NAME

GRANTEE NAME

ADDRESS 1

ADDRESS 2

CITY, STATE ZIPCODE

PHONE NUMBER

EMAIL ADDRESS

Your Consent

You have read this consent form. You have been given a chance to ask questions, and feel that all of your questions have been answered. You know that you are free to participate in the rapid HIV testing activities or not. You are signing below because you agree to participate in taking a rapid HIV test and completing the rapid HIV testing form.

____________________________________ __________________

Participant Name (Print) Date

____________________________________

Participant Signature

I acknowledge that I witnessed the participant sign this consent form.

_____________________________________ __________________

Witness Name (Print) Date

_____________________________________

Witness Signature

2