Consent - Intercept Survey

Form Approved

OMB No. 0920-0572

Expiration Date 03/31/2018

Submission under

0920-0572 Health Message Testing System

Attachment 17: Consent Form Intercept Interviews

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)

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 [insert concepts/messages/materials] that have been developed for [insert here]. RTI International, a not-for-profit research firm that conducts public health research, has been contracted to do intercept interviews with up to [insert here] 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 $20 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 _________________________