Att 3c Consent Form-Intercept

ATTACHMENT 3c:

INTERCEPT INTERVIEW

CONSENT FORM

Intercept Interview

Verbal Informed Consent Form

You are being asked to take part in a research study. This consent form tells you about the study and what you will be asked to do. You can choose to take part in the study or not.

The Centers for Disease Control and Prevention (CDC) is testing materials that have been developed for an HIV testing campaign. RTI International, a not-for-profit research firm that conducts public health research, has been contracted to do intercept interviews with up to 700 individuals to get their opinions and feedback about the materials.

RTI will summarize all responses in a single report. It will be impossible to determine what any one person said in response to these questions. Nothing you say will be linked to your name in the report.

There are no physical risks to participating. You may feel some mild distress or anxiety when discussing HIV/AIDS. Your participation will take approximately 20 minutes. There are no direct benefits for your participation. However, your input will help CDC improve the materials before a lot of people see them. In addition, you will receive up to $10 as a token of appreciation.

If you have any questions about your rights as a participant in this interview, you can call RTI’s Office of Research Protection at 1-866-214-2043. If you have any questions about the study, you may call the study director, Dr. Jennifer Uhrig, at 1-866-784-1953, extension 23311.

Do you consent to participate in the interview now?

__Yes

__No

Interviewer Initials _________________________