Att 3 Consent Form

Attachment 3: Web-based Survey Consent Form

Evaluating Social Marketing Campaigns Targeting Gay/Bisexual Men

Introduction and Purpose:

You have been asked to take part in a survey as part of a research study. The purpose of the survey is to hear your opinions about HIV-related topics and messages. RTI and ICF are conducting the survey. The survey is being administered by CMI. The survey is sponsored by the Centers for Disease Control and Prevention (CDC).

Procedures:

The survey is about HIV-related information and messages and should take approximately 30 minutes to complete if you are eligible for the study. At the end of the first section, you will be told if you are eligible to participate in the extended survey. You will be asked questions about your HIV status and your sexual behaviors and practices. Once you answer a question, you cannot go back and change your answer. Approximately 3,000 participants will take part in this study.

Risk/Discomforts and Right to Refuse or Withdraw:

It is up to you whether or not you take the full survey if you are eligible. You might feel embarrassed or upset by some questions in this survey. You can refuse to answer any questions for any reason. You can stop the survey at any time. There is a potential risk of breach of privacy if someone other than you finds out about your participation in the study.

Benefits:

There is no direct benefit to you for being in this study. However, you may learn more about ways to keep yourself safe and protected in your relationships. Your participation may help CDC learn more about providing programs to prevent HIV.

Privacy:

Your responses will be kept private to the extent allowable by law. No identifying information will be included on the survey. Your answers will not be shared outside of the research, and screening data is retained only for participants in the extended survey.

Token of Appreciation:

We will give you points redeemable for merchandise as a token of appreciation. This information will be kept separate from answers to survey questions. Participants cannot advance to the end of the survey just to collect points. Points are only dispersed when a participant completes the ENTIRE survey.

It is your choice to complete the survey. You can choose not to talk about any topic. You can stop taking the survey at any time.

Persons to Contact:

If you have questions about the survey, you can call Jennifer Uhrig (RTI International) at 919-316-3311 or Amee Bhalakia (ICF International) at 404-592-2182 between 9 a.m. and 5 p.m., Eastern Standard Time, Monday–Friday. If you have questions about your rights as a participant, you can call RTI’s Office of Research Protection toll-free at 1-866-214-2043 or ICF’s Office of Research Protection toll-free at (877) 556-2218 or [email protected]

Consent:

Please choose one to continue with the survey:

I have read this consent form and agree to participate in the survey. [GO TO Q1]

I have read this consent form and do not want to participate in the survey. [TERMINATE]