AA STD Disparities - Consent Forms

African American STD Disparities Health Communication Project

#0920-0798

Attachment 12

CONSENT FORMS

(PHASE I AND PHASE II)

Form Approved

OMB No. 0920-0798

Expiration Date: 01/31/2011

Consent Form—Triad Discussions

(Phase 1)

Reading level 7.3 (assessed by Flesch-Kincaid)

Introduction and Purpose:

You have been asked to be in a group discussion with up to 3 other people and a moderator. The purpose of the discussion is to hear about STDs and there impact on your community. RTI International, a non-profit company in North Carolina, is conducting the groups. The project is sponsored by the Centers for Disease Control and Prevention (CDC).

Procedures:

During the group, we will ask you to talk a little bit about yourself and to share what you know about STDs in community.

We will do 48 groups in five cities.

A moderator and an assistant will be there to guide the discussion and to take notes. CDC staff working on this project may observe the group through a one-way mirror.

Risk/Discomforts:

You might feel embarrassed or upset by the things that are talked about during the group. If that happens, we will refer you to someone who can talk with you about your concerns. You can refuse to talk about any topic for any reason. You can stop being in the group at any time. Someone you know could be in the group. We will ask everyone in the group to not talk about who is in the group or what is said in the group, but we cannot be sure that this information will be kept private. Please do not tell anyone about who is in the group or what you talk about today. We ask that all participants respect the comments and views of others in the group. Any participant who is disruptive will be immediately asked to leave the group.

Benefits:

There is no direct benefit to you for being in this group. However, you may learn more about STDS and your own risks. What we learn from the groups will help us to develop materials about STD prevention and testing.

Confidentiality:

We will be audio-taping the group. Tapes will be kept in a locked cabinet. They will be destroyed at the end of the project. Notes will be made of the tapes. We will only refer to first names in the notes. Your comments will be kept private to the extent allowable by law. The notes will be kept on a password-protected computer. Only authorized project staff will be able to see them. Any forms related to the project and/or that have your name or information that could identify you will be kept in a locked file cabinet. These forms will be destroyed once the project ends. However, there is still a small risk that your privacy could be broken.

Payment:

We will give you $50 to help repay you for your time, effort and travel expenses.

Right to Refuse or Withdraw:

It is your choice to be in this group. You can choose not to talk about any topic. You can stop being in the group at any time.

Persons to Contact:

If you have questions about the group, you can call Jennifer Uhrig (RTI) 1-800-334-8571 extension 3311. She can be reached between 9 AM and 5 PM Eastern Standard Time Monday – Friday. If you have questions about your rights as a participant, you can call RTI toll-free at 1-866-214-2043.

Your Consent:

I have read this consent form. I had a chance to ask questions and my questions were answered. I was given a copy of this consent form. I agree to be in the group.

PARTICIPANTS SIGNATURE

Please sign only your first name

Date

Witnesses Signature

Please sign your first and last name

Date

Consent Form- Individual Interviews

(Phase 1 & 2)

Reading level 7.5 (assessed by Flesch-Kincaid)

Introduction and Purpose:

You have been asked to take part in a one-on-one interview. The purpose of the interview is to hear about STDs and there impact on your community. RTI International, a non-profit company in North Carolina, is conducting the interview. The interview is sponsored by the Centers for Disease Control and Prevention (CDC).

Procedures:

During the interview, we will ask you to talk a little bit about yourself and what you know and hear about STDs in your community. The interview will take about an hour.

We will be doing interviews with people in 5 cities.

The person doing the interview will take notes. CDC staff working on this project may observe the interview through a one-way mirror.

Risk/Discomforts:

You might feel embarrassed or upset by the things that are talked about during the interview. If that happens, we will refer you to someone who can talk with you about your concerns. You can decline to talk about any topic for any reason. You can stop being in the interview at any time.

Benefits:

There is no direct benefit to you for being in this interview. However, you may learn more about STDs and your own risks. What we learn from the interview will help us to develop materials about STD prevention and testing.

Confidentiality:

We will be audio-taping the interview. Tapes will be kept in a locked cabinet. They will be destroyed at the end of the project. Notes will be made of the tapes. We will only refer to first names in the notes. Your comments will be kept private to the extent allowable by law. The notes will be kept on a password-protected computer. Only authorized project staff will be able to see them. Any forms related to the project that have your name or information that could identify you will be kept in a locked file cabinet. These forms will be destroyed at the end of the project. However, there is still a small risk that your privacy could be broken.

Also, any information that this local facility already has about you—because you have been in other projects—will still be kept there. You may be contacted by them to be in other projects in the future. If you have not been contacted by this facility before this project, they will not keep any of your contact information.

Payment:

We will give you $50 to help repay you for your time, effort and travel expenses.

Right to Refuse or Withdraw:

It is your choice to do this interview. You can choose not to talk about any topic. You can stop being in the interview at any time.

Persons to Contact:

If you have questions about the interview, you can call Jennifer Uhrig (RTI) 1-800-334-8571 extension 3311. She can be reached between 9 AM and 5 PM Eastern Standard Time Monday – Friday. If you have questions about your rights as a participant, you can call RTI toll-free at 1-866-214-2043.

Your Consent:

I have read this consent form. I had a chance to ask questions and my questions were answered. I was given a copy of this consent form. I agree to be in the interview.

PARTICIPANTS SIGNATURE

Please sign only your first name

Date

Witnesses Signature

Please sign your first and last name

Date