Form 0920- Guest Consent

Guest Consent

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Web-based Approaches to reach black or African American and Hispanic/Latino MSM for HIV Testing and Prevention Services

Attachment 4c

Guest Consent Form

Public reporting burden of this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

Informed Consent for Guest

This home HIV test kit has been distributed as part of a research study funded by the Centers for Disease Control and Prevention (CDC). On the following web pages, we will provide you with some help on how to use the HIV test kit, and ask you to provide some anonymous information as part of the study.

If participant clicks for more information, display:

The Emory University Rollins School of Public Health is doing a research study of home HIV testing. This study is to find out if men who were recruited from the Internet will test for HIV at home and if they will give test kits to people they know. What we learn will help create better HIV prevention programs for our community.

Thank you for taking the time to complete this survey! By continuing and using this website to answer questions about yourself and your previous testing experience, you are agreeing to be part of a research study.

If you have any questions, problems with using the tests, or if you test positive, you can call this toll-free study support number 24 hours a day, 7 days a week: 1-800-628-9240. If you have any questions or comments, you may contact study staff at [email protected] or (404) 727-4340, or the Principal Investigator, Dr. Patrick Sullivan of Emory University, at (404) 727-2038 or [email protected].

Questions marked with a red asterisk (*) are required questions that you must answer to move forward. You may choose to not answer any questions that make you feel uncomfortable. Your answers are private: the information you provide us will be kept secure and known only to study staff. This information will not be shared or used for any other research purposes.

This survey will ask questions about the recent study HIV self-tests that you have completed. If you have already reported some of the test results on a previous survey, please answer questions only relating to tests you have not already reported.

If you have any questions or feel you have been harmed in this study please contact a member of the research team:

Patrick Sullivan, DVM PhD

Emory University

Rollins School of Public Health

1518 Clifton Road NE

Atlanta, GA 30322

(404) 727-2038

If you have any questions about your rights as someone receiving a study home HIV test kit from a study participant or feel you have been harmed, you can contact the institutional review board at Emory University.

For Emory University contact:

Emory IRB

1599 Clifton Road

5th Floor East

Atlanta, GA 30322 USA

Tel: 404 712 0720

Toll free: 877 503 9797

Email:[email protected]