Att 8_Informed Consent Form

“Formative Research to Develop HIV Social Marketing Campaigns for Healthcare Providers”

Attachment 8: Informed Consent Form

Consent Form

Qualitative Data Collection Interviews

Formative Research, Evaluation Planning, and Evaluating HIV Prevention Social Marketing Campaigns

Introduction and Purpose:

You have been asked to take part in a research study. The purpose of the research is to conduct interviews to learn about your views related to a communications campaign. What we learn from this study will be used to develop materials for health care providers who deliver care to people with HIV. ___________________ (insert contractor name and description) is conducting the interview. The interview is sponsored by the Centers for Disease Control and Prevention (CDC).

Procedures:

During the interview, we will ask you about the discussions you have with your patients about HIV, some of whom may be HIV positive. The interview will take about an hour. About 600 physicians will take part in the interviews.

CDC staff working on this project may observe the interview through a one-way mirror or a live video-stream. There is also a note-taker taking notes behind a one-way mirror.

Before the interview, you will be asked to complete a computer assisted personal interview (CAPI) survey. Your name will not go on this survey. The survey will contain some general questions about your practice and your patient population.

Benefits:

There is no direct benefit to you for being in this interview. However, you may be exposed to educational materials that are designed to serve as resources to share with patients and for the provider to use in their day to day practice. You may find the discussion interesting and informative. What we learn from the interview will help us to develop materials and to make improvements to them at different stages of development.

Risks:

The questions we ask are not meant to be sensitive. Still, there is a chance that you may feel discomfort about some of the questions we ask. During both the interview and CAPI survey, you may choose not to answer any question you wish or end your participation at any time. We do not know of any other risks related to taking part in this study.

Privacy:

We will be audio recording the interview. A note taker is sitting behind a one-way mirror and possibly CDC staff may be watching in person or via a live video stream. Digital files from audio recordings will be kept on a password-protected computer, accessible only by authorized staff. Notes will be made of the audio recordings. We will keep the records for reference if needed to confirm the notes. We will only refer to people by their first name in the notes. All audio files will be destroyed three years after completion of the project. Your comments will be kept private to the extent allowable by law. The notes and survey data will also be kept on a password-protected computer. Only authorized project staff will be able to see them. Any forms related to the project that have your name or information that could identify you will be kept in a locked file cabinet. These forms will be destroyed after the interview ends. However, there is still a small risk that your privacy could be broken.

Also, any information that this local facility already has about you -- because you have been in other projects -- will still be kept there. You may be contacted by them to be in other projects in the future. If you have not been contacted by this facility before this project, they will not keep any of your contact information.

Token of Appreciation:

We will give you [INSERT AMOUNT] as a token of appreciation for your involvement.

Right to Refuse or Withdraw:

It is your choice to take part in this interview. You can choose not to talk about any topic. You can end the interview at any time. You can withdraw from the study for any reason at any time.

Persons to Contact:

If you have questions about the interview, you can call ____________________ (insert contractor name and contact information). S/he can be reached between 9 AM and 5 PM Eastern Standard Time Monday - Friday. If you have questions about your rights as a participant, you can call_______________________ (insert contractor number).

Your Consent:

I have read this consent form. I had a chance to ask questions and my questions were answered. I was given a copy of this consent form. I agree to be in the interview.

Signature

Date

Facilitator Signature

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