Att 3b Consent Form-Msg Testing-IDI FG

ATTACHMENT 3b:

MESSAGE, CONCEPT AND MATERIALS TESTING

INDIVIDUAL IN-DEPTH INTERVIEW AND FOCUS GROUP

CONSENT FORM

Consent Form –Message/Concept/Materials Testing

One-on-One Interviews and Focus Groups

Formative Research for the Development of CDC’s Act Against AIDS Social Marketing Campaigns Targeting Consumers

Introduction and Purpose:

You have been asked to take part in a one-on-one interview as part of a research study. The purpose of the interview is to hear your thoughts on materials that are being developed about HIV testing. RTI International, a non-profit company in North Carolina is doing the interview. The interview is sponsored by the Centers for Disease Control and Prevention (CDC).

Procedures:

During the interview/focus group [Circle One], we will ask you to talk a little bit about yourself and what you think and feel about various aspects of HIV such as HIV testing or HIV prevention. The interview, including the paper and pencil survey, will take about 1 hour and 15 minutes or 2 hours and 15 minutes [Circle One].

We will be doing interviews and focus groups with approximately 1000 people throughout the United States.

The person doing the interview will take notes. CDC staff working on this project may observe the interview through a one-way mirror.

Risk/Discomforts:

You might feel embarrassed or upset by the things that are talked about during the interview. If that happens, we will refer you to someone who can talk with you about your concerns. You can decline to talk about any topic for any reason. You can stop being in the interview at any time. Before or after the interview, you may be asked to fill out a paper and pencil survey. Your name will not go on this survey. The survey will contain some personal questions about your sexual behavior and HIV. It is your right to refuse to answer any questions or stop taking the survey at any time.

Benefits:

There is no direct benefit to you for being in this interview. However, you may learn more about your own risk behaviors and HIV. What we learn from the interview will help us to develop materials about HIV testing or HIV prevention.

Privacy:

We will be audio-taping the interview. Tapes will be kept in a locked cabinet. They will be destroyed at the end of the project. Notes will be made of the tapes. We will only refer to first names in the notes. Your comments will be kept secure to the extent allowable by law. The notes will be kept on a password-protected computer. Only authorized project staff will be able to see them. Any forms related to the project that have your name or information that could identify you will be kept in a locked file cabinet. These forms will be destroyed once the project ends. However, there is still a small risk that your privacy could be broken.

Also, any information that this local facility already has about you -- because you have been in other projects -- will still be kept there. You may be contacted by them to be in other projects in the future. If you have not been contacted by this facility before this project, they will not keep any of your contact information.

Payment:

You will receive $50 (interview) or $75 (focus group) as a token of our appreciation.

Right to Refuse or Withdraw:

It is your choice to do this interview. You can choose not to talk about any topic. You can stop being in the interview at any time.

Persons to Contact:

If you have questions about the interview, you can call Jennifer Uhrig at 1-800-334-8571 extension 3311. She can be reached between 9 AM and 5 PM Eastern Standard Time Monday - Friday. If you have questions about your rights as a participant, you can call Wendy Visscher of RTI’s Office of Research Protection toll-free at 1-866-214-2043.

Your Consent:

I have read this consent form. I had a chance to ask questions and my questions were answered. I was given a copy of this consent form. I agree to be in the interview.

Signature – First Name Only

Date

Facilitator Signature