Att 5 MARI Consent Form

Form Approved

OMB No. 0920-0840

Exp. Date 03/31/2027

Attachment 5: Consent Form

Public reporting burden of this collection of information is estimated to average 5 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-21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-0840)

Centers for Disease and Control Prevention

Consent to be in a Non-Research Program Evaluation

Thank you for your interest in this study. Before you decide to complete this survey, please read below and ask any questions to Dr. Kimberly Evans ([email protected]; 404-463-1440).

This study is being conducted by staff at the Centers for Disease Control and Prevention (CDC), Division of HIV Prevention, HIV Research Branch, Social Determinants of Health Research Team. We are asking you to be in this evaluation because you were a former CDC Minority HIV/AIDS Research Initiative (MARI) funding recipient. The purpose of this evaluation is to learn more about your research activities and funding experience, the impact of MARI on your career, and feedback on MARI as a research training program for early-career investigators, all so we can improve the MARI program.

We expect the survey to take you approximately 30 minutes to complete. There is low risk to you if you decide to participate in this evaluation. Some of the questions are personal. You do not have to respond to any questions you do not want to and you may stop at any time. There is no reimbursement or token of appreciation for taking part in this survey.

By participating in this evaluation, it will help CDC staff evaluate the impact of MARI as an early-career research training program and assess the impact of MARI on research and health outcomes within communities of color disproportionately affected by HIV. What you tell us will be kept private, and we will safeguard your identity and the information you share. Anonymous responses to the survey may be shared during national conferences and to write papers for submission to academic journals. At no time, will anyone be able to connect your name to what you said in your survey responses. We will also share our findings with you if you would like.

If you have any questions about this survey or your rights to being in this evaluation, you may call Dr. Kimberly Evans at 404-639-1440 or email at [email protected].

If you agree to be in this evaluation, please type your name in the box below. By signing your name, you also agree that you have read this information and have had a chance to ask any questions you may have about the evaluation.

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