Att. 4_Partner Survey Consent

Form Approved

OMB No: 0920-1161

Exp. Date: 02/29/2020

Evaluation of Enhancing HIV Prevention Communication and

Mobilization Efforts through Strategic Partnerships

Attachment 4

Partner Survey Consent Form

Introduction

You have been asked to take part in a survey as part of a research study. We are asking organizations to take part in a research study about HIV education and awareness practices and policies.

Procedures:

The survey should take approximately 30 minutes to complete. This survey is voluntary. It is your choice to complete the survey. You can choose not to respond about any topic. You can stop taking the survey at any time.

Risk/Discomforts:

There are no known physical risks to you from being in the study. The survey includes questions about your organization’s health/HIV programs and policies. You can decline to answer any question for any reason. You can stop the survey at any time.

Benefits:

There is no direct benefit to you for taking this survey. However, you may learn more about HIV and how you may enhance your organization’s offerings in this area.

Privacy:

Your responses will be kept private to the extent allowable by law. No identifying information will be included on the survey.

Persons to Contact:

If you have questions about the survey, you can call Dr. Jennifer Uhrig at 1-800-334-8571, extension 23311. 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:

Please choose one to continue with the survey:

I have read this consent form and agree to participate in the survey. [GO TO SURVEY]

I have read this consent form and do not want to participate in the survey. [TERMINATE]

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