Women's Health Needs STUDY_SCREENER

Women’s Health Needs Study Informed Consent to be a Research Participant

My name is _______________and I am working with NORC and the Centers for Disease Control and Prevention on this study.

Why we are doing this study? We are trying to find out about the health care needs of women age 18 to 49 years in your community. We plan on interviewing about 2,000 women for this study.

Who is funding this study? This study is funded by the Centers for Disease Control and Prevention.

What would I be asked to do if I am in this study? The interview will take you about 45 minutes. We will read you the questions in your preferred language. We will be asking you some questions to see if you are eligible to be in the study. These will be about things like where you and your family are from, what languages you speak, and if you have lived in certain countries. If you are eligible, give consent, and then choose to enroll in the study, then we will be asking you questions such as how long you have been in the US, if you have had a medical exam, your childbirth experiences, and what you and your family thinks about female circumcision and your experiences with female circumcision. Some of the study questions may make you feel uncomfortable. You can skip any question. Your answers are completely private and only results from the whole group of women will be included in any report.

How long will it take for me to participate in this study? For this study you will do one interview that will take about 45 minutes to complete. This will end your time in the study.

Are there any risks for me if I decide to participate? The risks to participating in this research are minimal. However, some of the questions are personal and might make you uncomfortable. You are free to skip or not answer any questions. You can stop at any time. I have community resources available for you if you need help finding support or services in your community.

If you choose to do the survey whether you complete the survey or not, you will not lose access to any services that you would otherwise be eligible for. Your answers will be kept private to the extent allowed by law and will be used only for research. The study has a Certificate of Confidentiality and a Privacy Certificate, so no one outside the study, even an official of the court, the government or law, can request your information. However, if interviewers and other study staff learn of immediate plans to have your minor daughter circumcised they may be legally obligated to report this as child abuse to state or local authorities The study does not ask you about circumcision in your daughter.

Employees of CDC, or experts and contractors working for CDC, may review information sent through computer networks to assess security. We will not collect your name or other information that identifies you during this interview. When results from this research are presented, we will not include any information that might be used to figure out who you are.

Are there any benefits for me if I decide to participate? There is no direct benefit to you for participating in the study. We believe the answers you provide will help us better understand the health care needs of women in your community.

Payment for participation: If you agree to be in this study we will give you $25 for your travel and/or child care expenses. In addition, if you recruit another women to be in this study, we will give you $10 for cell phone calls and/or transportation. You may recruit up to 3 women and receive $10 for each woman you recruit. You may need to contact these 3 women with our study invitation card. You will be able to receive a total of $55 reimbursement for expenses you may need to participate in the study and for recruiting up to three women.

A unique passcode will let us know which women you helped recruit so that we can reimburse you. Your name will not be collected at any time during this study.

Do I have to be in this study? No you do not. If you choose to be in this study, you can stop at any time and you are also free to skip or not answer any questions.

What happens if I would like to stop this interview? If you start the interview and decide to stop, that is perfectly OK. You will still receive the $25 for your travel and/or any child care expenses you may have during this interview. We will be able to keep and use the information you have shared up until that point. If you do not want your responses to be included, let us know and we will destroy your information.

Right to Ask Questions: Please contact the WHNS Study contact number with questions, complaints or concerns about this research at the toll-free phone number (866) 315-7130. If you have any questions or concerns about your rights as a research participant, please contact the NORC IRB Manager by toll-free phone number at (866) 309-0542. An Institutional Review Board (IRB) operates under Federal regulations and they review research involving human subjects to ensure the ethical, safe, and equitable treatment of study participants.

Do you have any questions about this study? If you have any questions or concerns regarding this study please ask. If you think of them later, contact the WHNS Study number at 866-315-7130.

What if I do not want to be in this study? If you do not wish to participate, we sincerely thank you for your time.

If you would like to participate: You must be 18 to 49 years of age to take part in this research study.

Participation in this study implies that you have reviewed and understand what is being asked of you for this study and that you are voluntarily willing to take part of this study. Your answers will be private and you can stop at any time.

Would you like a copy of this form?

ናይ መጽናዕቲ ድሌታት ናይ ደቀንስትዮ ጥዕና ኣብ ሓበሬታ ዝተመርኮሰ ምሃብ ፍቓድ ተሳታፊት ናይዚ መጽናዕቲ ንምዃን

ስመይ ____________ ይበሃል፡ ኣብዚ መጽናዕቲ ድማ ምስ NOCRን ምስ Centers for Disease Control and Prevention (ማእከላት ንምቁጽጻርን ምግታእን ሕማም) ይሰርሕ ኣለኹ።

ንምንታይ ነዚ መጽናዕቲ ንገብሮ ኣለና፧ ኣብ ማሕበረሰብኪ ካብ ዝቕመጣ ኣብ ውሽጢ ክሊ-ዕድመ 18 ክሳዕ 49 ዘለዋ ደቀንስትዮ ዘድልየን ናይ ክንክን ጥዕና ጠለባት ክንፈልጥ ንፍትን ኣለና። ንውዚ መጽናዕቲ እዚ ከባቢ 2,000 ደቂ-ኣንስትዮ ከነዘራርብ መዲብና ኣለና።

ነዚ መጽናዕቲ እዚ መን ይምውሎ ኣሎ፧ እዚ መጽናዕቲ ብCenters for Disease Control and Prevention (ማእከላት ንምቁጽጻርን ምግታእን ሕማም) እዩ ዝምወል ዘሎ

ኣብዚ መጽናዕቲ እንተድኣ ሃልየ እንታይ ክገብር ይሕተት ይኸውን፧ እቲ ቃለ-መሕትት ከባቢ 45 ደቓይቕ ክወስድ እዩ። ነቲ ሕቶታት ብዝመረጽክዮ ቋንቋ ከነንብበልኪ ኢና። ነዚ መጽናዕቲ ብቕዕቲ ዲኺ ኣይኮንክን ንምፍላጥ፡ ገለ ሕቶታት ክንሓተኪ ኢና። እዚ ከም ንስኽን ስድራቤትክን ኣበይ ትቕመጡ፡ እንታይ ዓይነት ቋንቋ ትዛረቡን ኣብ እተወሰነ ሃገር ተቐሚጥኩም ትፈልጡ’ዶ ዝኣመሰሉ ሕቶታት ዘጠቓልል ክኸውን እዩ። ብቕዕቲ እንተኣ ኴንኪ፡ ፍቓድኪ ሃቢ ከምኡ’ውን ኣብዚ መጽናዕቲ ንኽትምዝገቢ ድማ ምረጺ፡ ብድሕር'ዚ ከም ኣብ ሕቡራት መንግስታት ንኽንደይ ዝኣክል ግዜ ከምዝገበርኪ፡ ሕክምናዊ መርመራ ጌርኪ እንተድኣ ኾይንኪ፡ ናይ ወሊድ ተመክሮታትኪ፡ ከምኡ’ውን ንስኽን ስድራቤትክን ብዛዕባ ምኽንሻብ ጐለንስተይቲ ዘለኩም ኣተሓሳስባን ኣብ ምኽንሻብ ጓለንስተይቲ ዘለኪ ተመክሮን ዝኣመሰሉ ሕቶታት ክንሓተኪ ኢና። ገለ ካብቲ ናይ መጽናዕቲ ሕቶታት ዘይክሰማምዓኪ ይኽእል’ዩ። ዝኾነ ሕቶ ክትነጥርዮ ትኽእሊ ኢኺ። መልስታትኪ ምሉእ ብምሉእ ምስጢራዊ እዩ፡ ከምኡ’ውን ካብ መላእ እቲ ጉጅለ ደቀንስትዮ ዝኾኑ ውጽኢታት ጥራይ እዮም ኣብ ዝኾነ ጸብጻብ ዝጠቓለሉ።

ኣብዚ መጽናዕቲ ንኽሳተፍ ክንደይ ዝኸውን ግዜ ክወስደለይ እዩ፧ ነዚ መጽናዕቲ እዚ ሓደ ክባቢ 45 ደቓይቕ ዝወስድ ቃለ-መሕትት ክትገብሪ ኢኺ። ኣብቲ መጽናዕቲ ዘለኪ ጊዜ ብኸምዚ ክውዳእ’ዩ።

ንኽሳተፍ እንተድኣ ወሲነ ከጋጥሙኒ ዝኽእሉ ስግኣታት ኣለዉ ድዮም፧ ኣብቲ ምጽናዕቲ ብምስታፍ ዘጋጥሙ ስግኣታት ውሑዳት እዮም። እንተኾነ ግን፡ ገለ ሕቶታት ውልቃውያን እዮም፡ ዘይክሰማምዑኺ’ውን ይኽእሉ እዮም። ንዝኾነ ሕቶ ክትነጥሪ ወይ ድማ ከይመለስኪ ክትሓልፊ ትኽእሊ ኢኺ። ኣብ ዝኾነ ጊዜ ደው ከተብሊ ትኽእሊ ኢኺ። ኣብ ሕብረተሰብኪ ደገፋት ወይ ድማ ኣገልግሎታት ኣብ ምርካብ እንተድኣ ሓገዛት ደሊኺ፡ ንዓኺ ዝኸውን ናይ ማሕበረሰብ ምንጭታት ኣለውኒ።

ነቲ መርመራ ክትገበርዮ እንተድኣ መሪጽኪ፡ ነዚ መርመራ ወድእዮ ኣይትወድእዮ ብዘየገድስ፡ ነቲ ንኽትረኽብዮም ቅብልቲ ዝኾንክሎም ኣገልግሎታት ናይ ምርካብ ዕድል ኣይክትስእንን ኢኺ። መልስታትኪ ክሳዕ ሕጊ ዘፍቅዶ መጠን ምስጢራዊ ክኸውን እዩ፡ ከምኡ’ውን ንምርምር ጥራይ ከኣ ኣብ ጥቕሚ ክውዕል እዩ። እቲ መጽናዕቲ ናይ ምስጢራውነት ምስክር ወረቐትን ናይ ውልቃውነት ምስክር ወረቐትን ኣለዎ፡ ስለዚ ካብቲ መጽናዕቲ ወጻኢ፡ ዋላ ናይ ቤት ፍርዲ፡ መንግስቲ ወይ ሕጊ በዓል መዚ፡ ሓበሬታኺ ክሓትት ዝኽእል የለን። እንተኾነ ግን፡ ቃለ መሕትት ዝገብሩልክን ካልኦት ሰራሕተኛታትን፡ ንትሕትቲ ዕድመ ጓልኪ ናይ ምኽንሻብ ናይ ቀረባ መደባት ከምዘለኪ እንተድኣ ፈሊጦም፡ ንክፍለ-ሃገር ወይ ናይ ከባቢ ሰብ መዚ ከም ግፍዒ ናይ ህጻናት ክሕብሩ ብሕጊ ይግደዱ እዮም። እቲ መጽናዕቲ ብዛዕባ ናይ ጓልኪ ምኽንሻብ ኣይሓተክን እዩ።

ሰራሕተኛታት CDC፡ ወይ ምስ CDC ዝሰርሑ ክኢላታትን ተዃናተርትን፡ ውሕስነት ንምግምጋም ብመስመር መርበብ ኮምፒተር ዝመሓላለፍ ሓበሬታ ክለሳ ከካይዱ ይኽእሉ እዮም። ኣብ ግዜ ቃለ-መሕትት ንስምኪ ወይ ካልእ ንመንነትኪ ከለሊ ዝኽእል ሓበሬታ ኣይንእክብን ኢና። ናይዚ መጽናዕቲ እዚ ውጽኢታት ኣብ ዝቐርብሉ እዋን፡ ንስኺ መን ምዃንኪ ንምፍላጥ ክሕግዙ ዝኽእሉ ዝኾኑ ሓበሬታታት ኣይከነጠቓልልን ኢና።

ንኽሳተፍ እንተድኣ ወሲነ፡ ዝኾነ ዝወሃበኒ ረብሓታት ኣሎ ድዩ፧ ኣብቲ መጽናዕቲ ብምስታፍኪ ዝወሃበኪ ቀጥታዊ ረብሓ የለን። እቲ እትህብና መልሲ፡ ንኣብ ሕብረተሰብኪ ዘለዋ ደቀንስትዮ ናይ ክንክን ጥዕና ድሌታተን ብዝበለጸ ኣብ ምርዳእ ከም ዝሕግዘና ንኣምን።

ንምስታፍ ዝኸውን ክፍሊት፥ ኣብዚ መጽናዕቲ ክትሳተፊ እንተድኣ ተሰማሚዕኪ ንመጓዓዝያኽን ከምኡ ድማ/ወይ ንናይ ክንክን ቆልዓ ወጻኢታትኪ ዝኸውን $25 ክንህበኪ ኢና። ብተወሳኺ፡ ካልእ ደቀንስይቶ ኣብዚ መጽናዕቲ ንኽትሳተፋ እንተድኣ ኣምጺእኪ/መልሚልኪ ንጻውዒታት ሞባይል ቴሌፎንን መጓዓዝያን ዝኸውን $10 ክንህበኒ ኢና። ክሳዕ 3 ደቀንስትዮ ከተምጽኢ/ክትምልምሊ ትኽእሊ ኢኺ ንነፍስ ወከፍ ዘምጻእክያ ጓለንስተይቲ ከኣ $10 ክትወሃቢ ኢኺ። ነዘን 3 ደቀንስትዮ ብናይ መጽናዕቲ መዐደሚ ካርድና ክትውከስየን ትኽእሊ ኢኺ። ኣብዚ መጽናዕቲ ንኽትሳተፊ ዘድልየኪ ወጻኢታት ንምኽሓስን ክሳዕ ሰለስተ ደቀንስትዮ ብምምጻእክን ብድምር $55 ክትቅበሊ ክትክእሊ ኢኺ።

ምእንቲ ክንክሕሰኪ ክንክእል ፍሉይ ዝኾነ ምስጢራዊ ቁጽሪ/ኮድ ንየኖት ደቀንስትዮ ከም ዘምጻእኪ ክነግረና እዩ። ኣብ ዝኾነ እዋን እዚ ቃለ-መሕትት ኣብ ዝግበረሉ ጊዜ ስምኪ ኣይክእውሰድን’ዩ።

ኣብዚ መጽናዕቲ እዚ ክህሉ ኣለኒ ድዩ፧ ኣይፋልን፡ ግድን ኣይኮነን። ኣብዚ መጽናዕቲ ክትህልዊ እንተድኣ መሪጽኪ፡ ኣብ ዝኾነ ግዜ ከተቋርጺ ከምኡ’ውን ዝኾነ ሕቶ ክትነጥሪ ወይ ድማ ከይትምልሲ ናጻ ኢኺ።

ነዚ ቃለ-መሕትት ከቋርጾ እንተድኣ ደልየ እንታይ የጋጥም፧ ነቲ ቃለ-መሕትት ጀሚርኪ እንተድኣ ከተቋርጽዮ ወሲንኪ፡ ዝኾነ ጸገም ዘለዎ ኣይኮነን። ኣብዚ ቃለ-መሕትት ንዘጥፋእክዮ ወጻኢታት ናይ መጓዓዝያ ከምኡ’ውን/ወይ ንክንክን ውላድኪ ዝኸውን $25 ክትወሃቢ ኢኺ። ክሳዕ እቲ ጊዜ'ቲ ዝሃብክና ሓበሬታ ክንዕቅቦን ክንጥቀመሉን ክንክእል ኢና። መልስታትኪ ኣብቲ ጸብጻብ ክጠቓለል እንተድኣ ዘይደሊኺ፡ ኣፍልጥና ኢኺ፡ ንሕና ድማ ንሓበሬታኺ ክንድምስሶ ኢና።

ሕቶታት ናይ ምሕታት መሰል፥ ብኽብረትኪ ናብ ቁጽሪ ተሌፎን ናይ መጽናዕቲ WHNS ብዛዕባ እዚ መጽናዕቲ ሕቶታት፡ ጥርዓናት ወይ ድማ ስግኣታት ምስ ዝህልወኪ ርክብ ኣካይዲ በቲ ክፍሊት ዘይብሉ ቁጽሪ (866) 315-7130 ደውሊ። ከም ተሳታፊት ናይዚ መጽናዕቲ መጠን ብዛዕባ መሰላትኪ ሕቶታትን ስግኣታትን ምስ ዝህልዉኺ፡ ንኣመሓዳሪ ናይ NORC IRB ብክፍሊት ዘይብሉ ቁጽሪ ቴሌፎን (866) 309-0542 ክትረኽብዮ ትክእሊ። ሓደ Institutional Review Board (IRB, ቦርድ ትካላዊ ገምጋም) ኣብ ትሕቲ ፈደራላዊ ሕግታት እዩ ዝሰርሕ፡ ከምኡ’ውን ንስነ-ምግባራዊ፡ ውሑስን ማዕርነት ዘለዎ ኣተሓሕዛን ተሳተፍቲ መጽናዕቲ ንምርግጋጽ ሰባት ንዘሳትፍ ምርምር ይግምግሙ።

ብዛዕባ እዚ መጽናዕቲ ዝኾነ ሕቶታት ኣለውኺ ድዮም፧ ዝኾኑ ሕቶታት ወይ ስክፍታታት ብዛዕባ እዚ መጽናዕቲ እዚ ምስ ዝህልወኪ ብኽብረትኪ ሕተቲ። ድሒርኪ እንተድኣ ሓሲብክዮም፡ ንመጽናዕቲ WHNS ብቑጽሪ ተሌፎን 866-315-7130 ተወከስዮም።

ኣብዚ መጽናዕቲ ክህሉ እንተዘይደለኹ’ኸ፧ ክትሳተፊ እንተድኣ ዘይደሊኺ፡ ስለ ዝሃብክና ጊዜ ብጣዕሚ ነመስግነኪ።

ክትሳተፊ ምስ እትደልዪ፡ ኣብዚ ምርምራዊ መጽናዕቲ ክትሳተፊ ካብ 18 ክሳዕ 49 ዝዕድሜኺ ክትኮኒ ኣለኪ።

ኣብዚ መጽናዕቲ ምስታፍኪ፡ እንታይ ዓይነት ሕቶታት ኣብዚ መጽናዕቲ ከምትሕተትን ከምኡ’ውን ብወለንታኺ ኣብዚ መጽናዕቲ ትሳተፊ ከምዘለኺ እዩ ዝእምት። መልስታትኪ ምስጢራዊ እዩ ክኸውን ከምኡ’ውን ኣብ ዝኾነ ግዜ ከተቋርጺ ትኽእሊ ኢኺ።

ናይዚ ቅጥዒ/ፎርም'ዚ ቅዳሕ ትደልዪ ዲኺ፧

Flesch-Kincaid Grade Level 8.5