Consent

ATTACHMENT 4 Web-based Survey Consent Form

Development of Messages for the Act Against AIDS National Testing Campaign

Reading Level 7.2 (Assessed By Flesch-Kincaid)

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 International, a nonprofit research organization in North Carolina, is conducting the survey. The interview 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.

Risk/Discomforts:

There is no known physical risk to you from being in the study. You might feel embarrassed or upset by some questions on this survey. The survey includes questions about your background and your ideas and actions regarding HIV. It also asks your opinions about HIV ads. You can decline to answer any question for any reason. You can stop the survey at any time.

Benefits:

There is no direct benefit to you for taking this survey. However, you may learn more about HIV.

Privacy:

Your responses will be kept private to the extent allowable by law. No identifying information will be included on the survey.

Token of Appreciation:

We will give you points redeemable for merchandise as a token of our appreciation.

Right to Refuse or Withdraw:

It is your choice to do this survey. You can choose not to answer any question. You can stop taking the survey at any time.

Persons to Contact:

If you have questions about the survey, you can call Dr. Jennifer Uhrig at 1-800-334-8571, extension 23311. She can be reached 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.

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]