HIV Sample Consent Form

Sample Consent Form

CONSENT TO PARTICIPATE IN THE SUBSTANCE ABUSE AND HIV PREVENTION STUDY

Your participation is entirely voluntary. Please consider the information below and ask questions about anything you do not understand.

PURPOSE OF THE PROGRAM

The overall program goal is to prevent substance use and risky sexual behavior that can lead to acquiring or transmitting sexually transmitted diseases such as HIV and AIDS.

DESCRIPTION OF THE PROGRAM

The program consists of outreach to distribute educational materials, individual and/or group level interventions, HIV testing and referrals, environmental strategies to increase testing and education for large segments of the population, and referrals for alcohol and substance abuse screening and treatment.

PROCEDURES

• You will receive individual and/or group-level interventions consisting of __ sessions.

• To assess the effectiveness of this program in reaching its goals, you will be asked to participate in the evaluation component We will ask you to:

1) Complete a survey before the first session (baseline), after the last session (exit), and at 3 months post-exit. We will ask you questions about the following areas: 1) demographic information; 2) perception of risk of harming yourself by using drugs and alcohol; 3) perception of risk of harming yourself by having sex under the influence of drugs; 4) engagement in sexual risky behavior; 5) knowledge of HIV/AIDS transmission; and 6) social connectedness.

2) Provide primary and alternate contact information (including places that you are likely to frequent), so that we can contact you after you leave the program.

3) Participate in a customer satisfaction survey when you leave the program if you are selected to share your thoughts on the program.

• You will be offered HIV testing and counseling

POTENTIAL RISKS AND DISCOMFORTS

During your participation, you may disclose personal information or receive HIV testing results that may cause emotional discomfort or embarrassment. You will be provided counseling should an issue arise. Numerous precautions will be taken to ensure the privacy of interview and survey responses. In order to do this, an ID code number will be assigned to you. All records will remain locked to prevent disclosure. Information about a program participant, including whether or not the person is participating, will not be released without a subpoena or court order. Staff will comply with court orders and subpoenas for protected information in accordance with federal and state law.

ANTICIPATED BENEFITS TO INDIVIDUALS

Services will be provided which may increase your quality of life, including individual and group level interventions, HIV testing and counseling, and referrals for substance abuse screening and treatment. This improvement in the life of individuals will in turn benefit society as a whole.

PAYMENT FOR PARTICIPATION

Participation in this program is free. You will not have to pay to participate in any of the

Sample Consent Form ( continued)

services, and no monetary compensation will be provided for participating in the

program.

PRIVACY

All information you provide for this program is private and is protected by Federal and state laws and regulations. You will be assigned a code number, and all forms will use this number. All the information you provide will remain in a locked file cabinet to prevent disclosure. No information about you, or provided by you during participation in the program will be disclosed to others without your written permission, except:

• If it is necessary to protect your rights or welfare (for example, if you are injured and need emergency care),

• If it is required by law (i.e., child abuse or elder abuse), or

• If the information is subpoenaed by due process of law.

In addition, when the results of the program are published or discussed in conferences, no information will be included that would reveal your identity.

PARTICPATATION, WITHDRAWAL, AND RIGHTS

Your participation in the program is VOLUNTARY. You are free to withdraw your consent and discontinue participation without penalty at any time. You are not waiving any legal claims, rights or remedies because of participating in the program.

ALTERNATIVES TO PARTICIPATION

The alternative to participating in this program is not to participate. Individuals may still choose to participate in other services the agency/organization offers

SIGNATURE OF PARTICIPANT

I have read (or someone has read to me) and understand the information provided above. I have been given an opportunity to ask questions and all of my questions have been answered to my satisfaction. I have been given a copy of this form.

BY SIGNING THIS FORM, I WILLINGLY AGREE TO PARTICIPATE IN THE PROGRAM AND THE ASSESSMENT COMPONENT OF THE PROGRAM

__________________________________________________________________

Name of Participant Date

SIGNATURE OF STAFF

I have explained the intervention program to the participant, and answered all of his/her questions. I believe that he/she understands the information described in this document and freely consents to participate.

Name Signature of Staff Date:

(Must be the same date as participant)