Model Qualitative Community Key Informant Interview Consent Form

Appendix F Model Qualitative
Community Key Informant Interview Consent Form

National HIV Behavioral Surveillance

Brief HIV Biobehavioral Assessment

Community Key Informant Consent Form

A. Purpose

The [Agency Name] and the Centers for Disease Control and Prevention (CDC) are working on a project to learn about risk for HIV and to plan better HIV prevention and treatment programs for people in your community. The reason for this interview [brief description of purpose of interview]. We are asking you to participate in this interview because you may be able to provide us with information about this topic. The following information can help you make a choice about taking part in this interview.

B. Procedures

1. If you agree to be interviewed, we will talk for about 1 hour [or replace approximate time of interview].

2. During the interview, a staff member will ask you questions about the following topics:

• [list topics to be covered]

3. The interview will be audio-recorded [if applicable] and transcribed [if applicable]. [include additional details on how interview will be recorded and transcribed, including when the audio will be destroyed once the information is recorded in a transcript]

4. The interview and your responses are private. Your name will NOT be attached to this interview, the recording, the transcription, or later reports that may use your interview responses. We may share your anonymous responses with the CDC and other stakeholders.

5. You can refuse to answer a question at any time. If you do not answer a question or want to end the

interview, there will not be any penalty to you. No one except the project staff at [Agency Name] and the CDC will have access to the information you provide me.

C. Discomforts and Risks

There are no physical risks to you by participating in this interview. Some of the questions in the interview may make you feel uncomfortable.

D. Benefits

There are no direct benefits to you for being in this interview [replace if any benefits are provided with what benefits the participant will receive such as condoms, information on HIV/AIDS, or referrals for services]. The information you give us may help plan better HIV prevention and treatment programs.

E. Compensation

You will be paid [interview incentive] for the time you spend taking part in the interview. 

F. Persons to Contact

This project is run by: [name of principal investigator and phone number]. You may call them with any questions about being interviewed.

If you have questions about your rights as a participant or if you feel that you have been harmed, contact

[IRB committee or contact name and phone number].

G. Confidentiality Statement

What you tell us is private. No one except the project staff at [Agency Name] and CDC will have

access to your comments, except as otherwise required by law. [insert additional information about data security (e.g., transcription) as appropriate].

H. Right to Refuse or Withdraw

Doing this interview is VOLUNTARY. You have the right to refuse to answer any questions. You can

end the interview at any time you want.

I. Agreement

Do you have any questions?

Interviewer: Answer the participant’s questions about the interview before proceeding to the next

question.

You have read or had read to you the explanation of this interview, you have been given a copy of this form, the opportunity to discuss any questions that you might have and the right to refuse participation. I am going to ask for your consent to participate in this interview. By saying yes, you agree to participate in the interview. Do you agree to take part in the interview?

Date: ____________________ Interviewer initials in box confirm affirmative consent

[if Audio Recording] Do you agree to the use of audio recording for this interview?

Date: ____________________ Interviewer initials in box confirm affirmative consent

I have fully explained to the participant the nature and purpose of the procedures described above and the risks involved in its performance. I have asked if any questions have arisen regarding the procedures and have answered these questions to the best of my ability.

Date: ________________ Signature of interviewer: ____________________________