Interview Agreement - Category 1

Appendix 4e

Category 1
Staff Interview Agreement Form

Staff Interview Agreement Form

Purpose, Participation, and Procedures

This is a project funded by the Centers for Disease Control and Prevention (CDC) to look at (1) how (Agency Name) refers clients to HIV prevention and support services and (2) client outcomes from the referrals made. The findings may help (Agency Name) improve the way they provide HIV prevention and support services to people in the community in the future.

The staff interview will be conducted by CDC staff and will last one to 1.5 hours. During the interview, you will be asked questions about your experience with referring clients to HIV prevention and support services, as well as what you see as successes and barriers to connecting clients to those services. The interview will be audio-taped so it can be transcribed by a CDC staff member. Your name will not be recorded or included in the written document.

Your participation in this project is voluntary. You do not have to answer any questions you do not want to answer and can stop participating in the interview at any time. Not participating in this project will not affect your job or role at (Agency Name) in any way.

There is no direct benefit to you for being in the project, but what we learn from the project may help (Agency Name) improve the way they provide HIV prevention and support services to people in the community in the future.

Agreement Statement and Signature

Your participation in this project is voluntary. In other words, you decide if you want to participate in this project or not. If you agree to participate and later decide that you no longer want to, you can withdraw from the project at that time.

I agree to participate in this interview.

___________________________________________ ___________________

Participant Date

___________________________________________ ___________________

CDC Representative Date