USVI Contraceptive Consent Form

Consent Form –Formative Research to Inform the Development of Communications Related to Contraception and Zika

Focus Groups

Introduction and Purpose:

You have been asked to take part in a focus group (group interview) as part of a research study. The purpose of the focus group is to hear your thoughts on messages that are being developed about contraception use and the Zika virus. The focus group is sponsored by the Centers for Disease Control and Prevention (CDC).

Procedures:

During the focus group, we will ask you what you think and feel about the Zika virus and various aspects of birth control use such as knowledge of different birth control options or access to them. The focus group will take about 2 hours.

We will be doing focus groups with approximately 72 people in the U.S. Virgin Islands.

A facilitator will ask questions of the group and manage the group. One or two people from CDC will take notes. CDC staff working on this project may observe the focus group.

Risk/Discomforts:

You might feel embarrassed or upset by the things that are talked about during the interview. If that happens, we will refer you to someone who can talk with you about your concerns. You can decline to talk about any topic for any reason or refuse to answer any questions. You can stop being in the focus group at any time. The team will note first name, gender and age of focus group participant as well as the date and time of the interview. No other demographic data (full name, address, etc.) will be collected.

Benefits:

You will receive a gift card of $25 for your participation in this focus group. You may also learn important information about different methods of birth control that may be available to you. Your participation will also help develop important materials about contraception use that could be useful to you and/or many women in your community.

Privacy:

We will be audio-recorded during the focus group. Recordings will be kept in a [locked cabinet/secure online server]. They will be destroyed at the end of the project. Notes will be made of the [recording]. Your comments will be kept secure to the extent allowable by law. The notes will be kept on a password-protected computer. Only authorized project staff will be able to see them. These notes will be destroyed once the project 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.

Payment:

You will receive $25 as a token of our appreciation.

Right to Refuse or Withdraw:

It is your choice to do this focus group. You can choose not to talk about any topic. You can stop being in the focus group at any time.

Persons to Contact:

If you have questions about the focus group or questions about your rights as a participant, you can call Anna Brittain at 770-488-5515. She can be reached between 9 AM and 5 PM Eastern Standard Time Monday - Friday.

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 focus group.

Signature

Date

Facilitator Signature