Consent/Assent

Informed Consent/Assent Form and Information Sheet

Introduction and Purpose:

You have been asked to take part in a survey. This survey is part of a research study. The purpose of the survey is to learn your reasons for choosing an STD clinic for your health care. NORC at the University of Chicago (NORC) and the National Association of County and City Health Officials (NACCHO), are conducting the survey. The survey is sponsored by the Centers for Disease Control and Prevention (CDC).

Procedures:

The survey is about why you chose to come to this STD clinic. The survey will ask where else you could get health care for STDs if this clinic did not exist. The survey will also ask you some personal questions, such as whether you have STD symptoms and your sexual orientation. It should take about 10 minutes to complete. Your participation is completely voluntary. You may choose to skip any questions. You may end the survey at any time. You may ask the NORC interviewer questions at any time.

Eligibility

By agreeing to take this survey, you confirm that you are age 13 or older.

Risk/Discomforts and Right to Refuse or Withdraw:

You might feel embarrassed or upset by some questions in this survey. You can decline to answer any question. You can stop the survey at any time. If you become upset, we may notify clinic staff or direct you to clinic staff for assistance.

Benefits:

There is no direct benefit to you for taking this survey. However, you will help us to make sure that quality health care for STDs is available.

Confidentiality:

No information that identifies you will be asked in the survey. Responses from all participants will be combined. Information from this study cannot be linked to an individual participant. Please complete the survey in a private place. Your responses will be kept private to the extent that the law allows.

Payment:

No payment will be given for your participation. It is your choice to complete the survey. You can decline to answer any questions for any reason. You can stop the survey at any time.

Persons to Contact:

If you have questions about the survey, you can call Sara Walsh with NORC at 1-312-759-4003. She can be reached between 9 a.m. and 5 p.m., Central Standard Time, Monday through Friday. You may also contact our project at our toll free number 877-898-5903 or by email at [email protected]. If you have questions about your rights as a participant, please call the NORC Institutional Review Board at 1-866-309-0542.