DSTP Assessment of STD Clinic Users

Form Approved

OMB No. 0920-0840

Expiration Date 02/29/2016

Sub-collection Under the Approved Generic ICR:

Formative Research and Tool Development

OMB No. 0920-0840, Expiration 02/29/2016

DSTDP Assessment of STD Clinic Users

Attachment 2

Verbal Informed Consent Script/Information Sheet

March 11, 2013

Verbal Informed Consent Script/Information Sheet

Introduction and Purpose:

You have been asked to take part in a survey that is part of a research study. The purpose of the survey is to learn your reasons for choosing an STD clinic for your health care. [INSERT VENDOR NAME] and the National Association of County and City Health Officials (NACCHO), a nonprofit organization in Washington, DC, are conducting the survey. The survey is sponsored by the Centers for Disease Control and Prevention (CDC).

Procedures:

The survey is about your reasons for choosing this STD clinic, and where else you could get health care for STDs if this clinic did not exist. It should take about 10 minutes to complete. The survey will ask you some personal questions, such as whether you have STD symptoms and about your sexual orientation.

Risk/Discomforts and Right to Refuse or Withdraw:

You might feel embarrassed or upset by some questions in this survey. You can decline to answer any questions for any reason. You can stop the survey at any time.

Benefits:

There is no direct benefit to you for taking this survey. However, you will help us to make sure that quality health care for STDs is available.

Confidentiality:

No identifying information will be included in the survey. Survey responses from all participants will be combined, so that information cannot be linked to an individual participant. We encourage you to complete the survey in a private place. Your responses will be kept private to the extent that the law allows.

Payment:

No payment will be provided for your participation. It is your choice to complete the survey. You can decline to answer any questions for any reason. You can stop the survey at any time.

Persons to Contact:

If you have questions about the survey or your rights as a participant, you can call Karen Hoover at 1-800-232-4636. She can be reached between 9 a.m. and 5 p.m., Eastern Standard Time, Monday through Friday.

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