Consumer - Consent

Form Approved

OMB No. 0920-0572

Expiration Date 03/31/2018

Submission under

0920-0572 Health Message Testing System

Attachment 14: Consumer In-Depth Interview/Focus Group Consent Form

Public reporting burden of this collection of information is estimated to average 2 hours 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: OMB-PRA (0920-0572)

Consent Form – [INSERT MATERIAL TYPE] Testing

In-Depth Interviews and Focus Groups

Introduction and Purpose:

You have been asked to take part in a [one-on-one interview/focus group] as part of a research study. The purpose of the interview is to hear your thoughts on [INSERT TOPIC] that are being developed about HIV [INSERT TOPIC]. 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 [INSERT TOPIC]. The interview, including the brief survey, will take about 1 hour.

We will be doing interviews and focus groups with approximately [INSERT NUMBER] people throughout the United States.

There is another researcher taking notes. CDC staff working on this project may observe the interview through a one-way mirror or a live video or audio-stream.

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 brief 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 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 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