Consent Form

Form Approved

OMB No. 0920-0840

Expiration Date: 1/31/2019

Project Engage: Engaging Gay “Community” Activism for Syphilis Prevention

Generic Information Collection Request under OMB #0920-0840

Attachment #4

Consent Form

Public reporting burden of this collection of information is estimated to average 0 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: OMB-PRA (0920-0840)

Project Engage-Project Information and Consent Form

Thank you for your interest in this research study. My name is Brittany Bickford and I am a Senior Research and Evaluation Analyst at the National Network of Public Health Institutes (NNPHI).

Before you decide whether to agree to be in this study, please read this form along with me as I read it aloud and ask as many questions as you need to be sure you know what you will be asked to do.

Introduction: This study is being done by researchers from the Divisions of STD and HIV Prevention, Centers for Disease Control and Prevention (CDC).

What is the purpose of this study? The purpose of this study is to learn about how you and other men think about community—what communities you feel part of and why—and about sexual health. Our goal is to use the information to inform community engagement and mobilization efforts, and make it more relevant for people who are most at risk for STDs.

Why am I being asked to be in this study? We are asking you to be in this study because we are conducting a number of interviews with African American men who have sex with men in both New Orleans and Washington DC.

[Key Informants only]Additionally you were selected because you have been identified as a person who has been active in efforts to improve sexual health among men in your community, based on your work with [insert organization affiliation].

How long will you need me? We expect the interview to take no longer than one hour.

What is going to happen during the study? As stated before, we will ask you some questions and talk with you by phone. I will be asking the questions and my co-worker will listen and take notes. Also, we will record what you say on audio tape. This is so we have an accurate record of what you say.

What do you want me to do if I decide to be in this study? During the interview, you will be asked to tell us your thoughts about community and sexual health. We are asking you to give us your honest opinions and views on the topic. There are no wrong or right answers.

Are there any risks to me if I decide to be in this study? There is low risk to you if you decide to be in this study. Since we may ask you several personal questions during the interview, you may feel uneasy or uncomfortable. You do not have to answer any questions you do not want to during the interview. You may stop the interview at any time.

Are there any benefits from being in this study? By being in this study you may be able to help us improve education and outreach about sexual health for other men who have sex with men. Knowing how men feel about this topic may help us create better ways to reach and educate people, or to deliver services to people who need them. This may help us prevent or reduce STDs like syphilis, gonorrhea, and HIV.

Will the things I tell you be kept private? What you tell us will be kept private to the extent allowed by law. The things you tell us during the interview will be kept secure by the research staff. We will protect your identity and information that you give us. That is, we will not tell anyone what you said and we will not tell anyone that you were part of this study. However, if we think there may be child abuse or that you may cause harm to yourself or others, we are required by law to report this concern to the proper authorities.

What is going to happen with the audio tapes of my interview? After the interview, a person working on the study will listen to the audio tape and transcribe what was said. Only the people working on the study will be able to listen to the tapes. At the end of the study, we will erase the tapes and throw them away.

What will you do with my interview? The tapes and transcripts from your interview will be used to write a report on what we have found. The people working on the study will review all the interview responses to help us understand what we have found. We may also publish a paper in a journal, so that we can share what we found with other people. We will not use your name in the report or in any papers we write, and nothing that you say will be directly connected to you. We will do our best to ensure that no one will be able to know what you said or that you were in this study from anything that we write. We will destroy all records with your contact information after the study is complete.

Is there any cost if I take part in this study? The only cost to you for being in this study is your time for taking part in the phone interview. t.

Is there any reimbursement if I take part in this study? There is no reimbursement for taking part in this study, although your will receive a token of appreciation of a $40 Amazon gift card for your participation.

Who should I call if I have questions about this study or think I may have gotten sick or been harmed by this study? If you have any questions about this study or your rights for being in this study, you may call Aaron Alford at 202.830.0771, or the Michigan Public Health Institute at 517-324-7387.

Do I have to be in this study? You do not have to be in this study. It is up to you if you want to or not. You can stop being in this study at any time without any penalty or loss of benefits.

Do you have any further questions about this study?

Do you wish to proceed?

To ensure everything is captured accurately I would like to record today’s interview. Do I have your permission to record?

[Turn recorder on.]

Since we are now on the record I’d like to go over once again why we are meeting today.

[Restate purpose of the interview, confirm that the participant read or was read the consent form and was offered a chance to ask questions.]

I’d like to confirm once again that you wish to proceed with this interview?