Att 4c HIV-Neg MSM Assent Form_English

Attachment 4c.

Pulse Assent – English

Study No.: «ID»

Emory University IRB IRB use only

Document Approved On: «ApproveDate»

Form Approved

OMB No: 0920-New

Exp. Date: XX/XX/XXXX

Understanding Barriers and Facilitators to HIV prevention for

Men Who Have Sex with Men (MSM) – Pulse Study

Attachment 4c HIV-Negative MSM Assent Form_English

Public reporting burden of this collection of information is estimated to average 3 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-New)

Emory University School of Medicine, Department of Medicine,

In Collaboration with Research Support Services, Inc.,

Sponsor: The US Centers for Disease Control and Prevention

Study Title: Understanding Barriers and Facilitators to HIV Prevention for Men Who Have Sex with Men (MSM) – Pulse Study

Principal Investigator: Paula M. Frew, PhD, MA, MPH

Sponsor’s Name: Centers for Disease Control and Prevention.

ASSENT FROM PEDIATRIC SUBJECTS

Subject age:_______ years

_____WRITTEN ASSENT (ages 13-17)

WRITTEN ASSENT DOCUMENT

We are asking you to volunteer to be in a research study. We will ask you some questions about HIV risk. The purpose of the study is to make programs to help young men like you not get HIV. We will interview 150 males as a part of this study. We will talk to you for about an hour. We will record our talk and take notes. After the questions are over, we will write up what you told us. We will not use your name or any other names you might tell us in our documents.

There are no known direct risks of being in this study. There is always a slight risk that any personal information given may not be fully protected. We will make sure this does not happen by using a study number instead of your name on our forms. In order to reach you we have your name, contact information and your study number. That information is kept locked separately from our forms in the office. Outside of the office your name and contact information will not have a study number. When we type up your interview, we will not use your name. We will take out any names you say. You are also welcome to skip any question you do not wish to answer. We also keep all study materials in a locked cabinet in a secure area.

The study staff will be able to see your answers and anything private you might tell us. We are required by law to report some things you might say about sex with someone who is older or younger than you or if you intend to harm yourself or someone else.

Right after you finish talking with us, we will give you $40 in the form of (cash/ a gift card). You will get $40 in cash or in a gift card even if you do not choose to complete the study.

You can refuse (say no) to be in this study. The research staff cannot make you be in the study if you don’t want to be. If you agree to be in the study but change your mind about it later, you can stop being in the study. If you don’t want to do the study, it will not change any treatments or services that you currently get or you might get in the future. You can keep a copy of this form. Take your time to decide if you want to be in the study.

If you agree to be in the study, sign here:

Name of Participant

Signature of Participant Date Time

Person Obtaining Assent Date Time

IRB Form: xxx Version date: MM/DD/YYYY

OMB #: xxxx-xxxxx Expiration Date: 00/00/0000