Interview Consent Form

Interview Consent Form

[Interviewer reads consent form prior to interview]

Subject ID: ______________

Introduction and Purpose:

• This study is about women who had Zika when they were pregnant and their babies.

• We want to learn about their experiences so we can make health services better for mothers and babies affected by Zika.

Procedures:

• The interview will take up to one hour to complete. We are conducting interviews with about 100 mothers in Virginia and Pennsylvania.

• During the interview, I will ask you questions about any health services you and your baby got from doctors.

• If you agree, I will record our conversation so I can fill in my notes from our talk.

Benefits and Risks:

• Some of the questions about your baby may make you feel emotional or uncomfortable. Although the questions we ask are not meant to be sensitive, there is a chance that you may feel uncomfortable with some of the questions.

• You do not have to answer any question that you don’t want to answer, and you can stop the interview at any time.

• You will get a $75 VISA gift card at the end of the interview.

Confidentiality:

• Your name and information about you will be kept private.

Right to Refuse or Withdraw:

• It is your choice to do this interview.

• You can stop the interview at any point.

Persons to Contact:

• If you have questions about the study, you can call the project director, Dr. Linda Squiers, at 1-800-334-8571, ext. 25128 (toll free).

• If you have any questions about your rights as a participant, you can call RTI’s Office of Research Protection toll-free at 1-866-214-2043

Do you have any questions at this time?

Your Consent:

If you want to do this interview, say “yes”, and if you do not want to participate just tell me “no.”

Do you want to do this interview?

• Yes

• No

Interviewer Name:____________________________

Interviewer Signature: _________________________ Date: ____________________

Do you have any questions before we begin?