Consent

INFORMED CONSENT

Enhanced Surveillance of Respiratory Illness Among People Experiencing Homelessness in Anchorage, Alaska

1.INTRODUCTION:

This form is to tell you about an activity you can take part in. Taking part in this project is voluntary. You may take yourself out of the project at any time without losing care or services. By signing this consent form and agreeing to be in this project you are not giving up any of your rights. This public health surveillance project is being done by local partners including Anchorage Health Department and the Centers for Disease Control and Prevention (CDC). After you finish reading this consent form, we will answer any questions you may have.

2.A. PURPOSE OF THIS ACTIVITY:

The goal of this project is to understand what microorganisms (viruses or bacteria) cause respiratory illnesses among people experiencing homelessness in Anchorage, how their living conditions could affect their risk of getting respiratory illnesses, and how these could be prevented.

B.ACTIVITY DURATION:

This project will continue until March of 2023. Signing the consent form for this project does not obligate you in any way for future project procedures. You are able to withdraw from participation at any time.

C.WHAT THIS ACTIVITY INVOLVES:

The project nurse will collect a nasopharyngeal sample (back of your nose) with a swab, to be able to test for multiple microorganisms, including COVID-19, that may be causing the symptoms you currently have. You may have had a similar sample collected if you have been previously tested for the virus that causes COVID-19.

The nurse will also ask you about information related to your health and your symptoms.

3.RISKS AND DISCOMFORTS:

We do not expect any serious side effects from the nasopharyngeal sample, only maybe some discomfort while the sample is being collected. Your medical care will not be affected by participating or not participating in this activity. We will use an identification number rather than your name or other personal information on all the information and samples we have related to you in this project. That means that if someone sees the information, they will not know it came from you. When we present the information from this activity, we would never use your name.

4.A.BENEFITS OF PARTICIPATION:

This project probably will not benefit you directly. This project will help us learn more about respiratory diseases in people experiencing homelessness in Anchorage and find ways to protect them. You will not get individual test results. However, data from this project will be shared with medical providers. This project may help providers learn more about the respiratory illnesses present in the people experiencing homelessness in Anchorage.

B.REIMBURSEMENT FOR TIME:

Reimbursement will be provided for your time and for providing a sample during your visit. You will receive a reimbursement of $25 in a gift card.

5.CONDITIONS OF THE ACTIVITY:

You might be contacted in the future to see if you want to participate in a similar project. If you have any questions about this project or if you are concerned about this project, you may contact the investigators, #### by calling 1-800-699-0767 toll free or 907-729-3400. If you think that you have not been treated fairly, or have been hurt by joining the project, or you have questions about your rights in this project, please contact the Alaska Area IRB Administrator (Yvonne R. Tanape-Druce) at 907-729-3924, (collect calls accepted) or by email: [email protected] of the Alaska Area Institutional Review Board (IRB).

APPROVAL:

I have read or was told about this project and all of my questions have been answered to my satisfaction. I have been offered a copy of this consent. I agree to be in the project and to:

□ Nasopharyngeal sample collection, testing for viral and bacterial pathogens

Name of Participant: ____________________ Date of Birth: ______________

X_______________________________ __________________

Signature Date

V 1.0 July 2022