Consent

Form Approved

OMB No.0920-1011

Exp. Date 3/31/2017

Appendix 3 : Consent Form

Investigation of Crimean-Congo hemorrhagic fever in Georgia, 2014

Hello my name is ______________________________, I am with the Centers for Disease Control and Prevention on behalf of the National Center for Disease Control and Public Health. During the past few months in Georgia there have been some cases of a disease called Crimean-Congo hemorrhagic fever. We are trying to better understand why some Georgians have become ill with Crimean-Congo hemorrhagic fever. We would like to administer a brief questionnaire to you and to draw blood from you. We hope to use the results of our investigation to help prevent future illness in Georgians.

We would like to take a small sample of blood from your arm to find out if you were infected with the Crimean-Congo hemorrhagic fever virus recently or in the past. There may be a small risk with the blood sample collection including discomfort, bruising, or bleeding at the site of the blood draw.

The benefits of participating in this investigation and the testing will be that you will know if you were infected with the virus, and the information from this investigation will help the Georgian government prevent people from becoming infected with this virus in Georgia in the future.

All the information you share with us will be kept completely private. You are free to choose whether or not to participate in this investigation, and you can withdraw from any part of this investigation at any time. 

1. Would you be willing to take about 30 minutes to answer some questions about yourself and your activities prior to your illness?  

If yes: Thank you. <go to question 2>

If no: Why don’t you want to take the survey? _______________________________

Would another day or time be more convenient for you? Yes No

If yes: When? ____________________________

If no: Can you give us some very basic information?

Where is your residence? (village/region/district)________________

What is your date of birth? __ __ /__ __ / __ __ __ __

D D M M Y Y Y Y

What is your sex? Male, Female (circle one)

What is your nationality: Georgian, Azery, Armenian (circle one)

2. Would you be willing to have your blood drawn?

If yes: Thank you. Let’s get started with the questions. <Go to the KAP questionnaire>

If no: Why don’t you want to have your blood drawn? _____________________________

Can you give us some very basic information?

Where is your residence? (village/region/district)________________

What is your date of birth? __ __ /__ __ / __ __ __ __

D D M M Y Y Y Y

What is your sex? Male, Female (circle one)

What is your nationality: Georgian, Azery, Armenian (circle one)

Thank you so much for your time and consideration.

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)