Sample Consent Forms

Data Collection Through Web Based Surveys for Evaluating Act Against AIDS Social Marketing Campaign Phases Targeting Consumers

OMB No. 0920-0920

Attachment 4

Sample Participant Consent Form

You have been asked to take part in an online survey about [INSERT TOPIC]. If you take part, you will be one of about [INSERT SAMPLE SIZE] people to do so. You are being invited to take part in this study because you may have important insights about [INSERT TOPIC].

RTI International, a non-profit research institute located in North Carolina, is conducting the survey. The study is sponsored by the Centers for Disease Control and Prevention (CDC).

Procedures

First, we will ask you some questions to find out if you are eligible to participate in this survey which should take about 2 minutes. Some of these questions are about sensitive topics such as HIV and [INSERT TOPICS]. Second, if you are eligible, we will ask you to complete a 30-minute survey. The survey asks questions about [INSERT TOPIC] and for your opinions on [advertisements/messages] that may be used to [INSERT GOAL OF ADVERTISEMENTS/MESSAGES]. It is your choice to participate in the study. You will not be contacted in the future about this study after your participation ends.

Risk/Discomforts and Right to Refuse or Withdraw

You might feel embarrassed or upset by some of the questions that will be asked. You can decline to answer any questions for any reason, and you can stop participating at any time without penalty. There is also a potential risk of loss of confidentiality. Every effort will be made to protect your information, but this cannot be guaranteed.

Benefits

You will not get any personal benefit from taking part in this study. However, your responses are very important because they will help CDC understand how people may respond to potential [advertisements/messages] that could be used to [INSERT GOAL OF ADVERTISEMENTS/MESSAGES].

Remuneration

We will give you [INSERT AMOUNT OF POINTS] as a token of appreciation for taking part in the study.

Privacy and Confidentiality

The privacy and confidentiality of your information is very important to us, and we are committed to maintaining a secure environment in which you can participate. All information collected in this survey will be kept confidential to the extent provided by law. Only [VENDOR NAME] knows your name and e‑mail address; RTI and CDC cannot access this information. Only RTI and CDC can access the survey data; [VENDOR NAME] cannot access this information. This means that your name and email address cannot be linked to your survey answers.

(If applicable: [VENDOR NAME] will also record participants’ IP addresses to help make sure that people do not complete the study more than once. IP addresses will be destroyed by [VENDOR NAME] and RTI after all data are collected; CDC will not have access to this information. Your IP address cannot be linked to your survey answers after they are deleted.)

To help protect your privacy, take the survey in a private location, such as your own home and/or in a room with a door, and close your browser window when you are finished or if you decide to stop participating after you already started.

Persons to Contact

If you have questions about the study, you can call Dr. Jennifer Uhrig at 1-800-334-8571, extension 2-3311. She can be reached between 9 a.m. and 5 p.m., Eastern Standard Time, Monday–Friday. If you have questions about your rights as a participant, you can call RTI’s Office of Research Protection toll-free at 1-866-214-2043.

Consent

I understand that it is my choice to participate in this survey. I may refuse to participate or stop participating without penalty.

Please choose one:

I have read this consent form and agree to participate in the survey.

I have read this consent form and do not want to participate in the survey

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