Web-based Informed Consent - HWC

Attachment 9

Web-based Informed Consent Form for HWC Questionnaire

Purpose of the survey: [LEA name] is a part of an HIV- and STD-prevention project funded by the CDC’s Division of Adolescent and School Health. This project deals with sexual health and social services. It also deals with referrals to those services, and school climate and safety. This project focuses on meeting the needs of youth who identify as lesbian, gay, bisexual, transgender, and questioning (LGBTQ). In particular, this project focuses on males who identify as gay or bisexual, engage in sexual activities with other males, or are attracted to other males. ICF International (ICF) is helping the district to learn the impact of this project. The school district identified your health or wellness center (HWC) as a partner. As a staff member at the HWC, you are being asked to help us with this project by taking a survey. Staff from up to 10 HWCs are being asked to take this survey. This survey asks about the services offered by your HWC. The survey also asks about your HWC’s relationships with the school district and specific schools. Staff from community based organizations that work with the district are also being asked to take a similar survey.

What you will do: You will use a computer to fill out a Web-based survey. The questions will gather information about your HWC. If needed, please consult with other staff from your HWC to answer all the questions. You will not be asked to answer any questions of a personal nature.

Time needed: The survey should take about 40-60 minutes to complete.

Possible risks: There are no known risks associated with taking this survey. Taking this survey is voluntary. You may stop taking the survey at any time for any reason. Your responses will not be linked with your name or your HWC’s name without your permission. Your name and role will not be included in any reports. [LEA name] will receive a summary report, but this report will only contain summarized data and will not include your individual responses.

Benefits: If you take this survey, it will give you the chance to share information about your HWC. We will also learn about your HWC’s relationships with schools. By taking this survey, you will help inform the services offered to youth in your community, including LGBTQ youth.

Deciding not to take the survey: Taking this survey is voluntary. You can choose to take it or not to take it. If you choose to take the survey, you can stop at any time. If you decide not to take it, or decide to stop answering the questions at any point during the survey, it will not be held against you in any way.

Persons to Contact: If you have any questions about how the study works, you can call Catherine Lesesne at ICF at (404) 592-2230. If you have any concerns about your rights in the study, you can call the ICF Institutional Review Board at (877) 556-2218.

Clicking “yes” below means that you agree to take the survey. If you wish to stop at any time, click the “exit” button at the bottom of the screen; you will see a box asking you if you want to save your answers or erase them. Thank you.

Yes - I have read the informed consent statement and agree to participate in the survey

No – I do not agree to participate in the survey