Att 4_Consent Form

Form Approved

OMB No. 0920-0840

Expiration Date: 01/31/2019

Project Engage 2.0: Engaging Gay “Community” Activism for Syphilis Prevention

Generic Information Collection Request under OMB #0920-0840

Attachment #4

Consent Form

Project Engage-Project Information and Informed Consent

[To be read and signed by each focus group participant one-on-one before focus group begins as well as to be provided in hard copy to each participant.]

Thank you for your interest in this research study. My name is [Insert Name] 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 listen as I read a form aloud and follow along on your own form 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—and about sexual health. Our goal is to use the information to inform STD prevention efforts.

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 focus groups with African American men who have sex with men in both New Orleans and Washington DC.

How long will you need me? We expect the focus group to take no longer than 90 minutes.

What is going to happen during the study? We will ask everyone questions today. We hope for equal participation from everyone sitting here. 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 focus group, 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. It is possible that some of the questions may make you feel uneasy or uncomfortable. You do not have to answer any questions you do not want to during the focus group. You may leave the focus group at any time you wish.

Are there any benefits from being in this study? By being in this study you may be able to help us improve education 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 focus group 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. Also, by signing this you are agreeing to keep the things that are shared by other participants’ private- as in, “what happens in this room stays in this room.”

What is going to happen with the audio tapes of the focus group? After the focus group, 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 the focus group transcripts? 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 focus group 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 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 $50 Visa 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, you may call Aaron Alford at 202.830.0771. If you have questions about your rights as a participant in this study, call the Michigan Public Health Institute Institutional Review Board 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.

Permission to record _____Yes _____No

Name _________________________________________________

Signature _________________________________________________

Date ­­_______________________