Consent Form

“CBO Needs Assessment for Preparedness and Resources for

Support of Biomedical HIV Prevention”

Attachment 8 Consent Form

Consent Form

Title: CBO Needs Assessment for Preparedness and Resources for Support of Biomedical HIV Prevention

Principal Investigator: Dawn Smith, MD, MS, MPH

Introduction

You are being asked to be in a study that will be conducted by Centers for Disease Control and Prevention. The study is an online survey. This survey will attempt to learn more about the needs of Community Based Organizations (CBOs) regarding biomedical interventions. The survey data will help researchers develop tools and trainings to help CBOs implement HIV biomedical interventions.

Purpose

The study aims to assess the interest and current capacity of CBOs to implement biomedical interventions.

Procedures

If you agree to be in this study, you will be linked directly to the web survey.

The survey will ask questions about your organization’s capacity to implement biomedical interventions. It will take about 30 minutes.

You may refuse to answer any questions at any time for any reason. If you refuse to answer a question you will not be punished in any way.

Risks and Discomforts
There are no risks with being in this study. You may feel uncertain when answering some questions, but you always have the right to skip a question that you do not want to answer.

Benefits

This study is not designed to benefit you directly. This study will help researchers develop tools and trainings to help CBOs similar to yours implement HIV biomedical interventions.

Token of Appreciation

You will not receive any token of appreciation for being in this study.

Privacy

What you tell us is private except as otherwise required by law. Study staff at CDC can see the data.

Authorization to Use and Disclose Health Information

If you agree with this document and take part in this study, you are allowing the study staff CDC to use or release information from the survey.

Costs

You will not be charged any costs for participating in this study.

Voluntary Participation and Withdrawal from the Study

Your choice to be in this study is up to you. You have the right to not be in this study. You also have the right to stop the survey at any time. If you want one, you may print a copy of this form to keep.

Contact Persons

If you have any questions about the study, please contact the investigator in charge, Dr. Dawn Smith, Principal Investigator at (404) 639-5166 Email: dsmith1@cdc.gov

Consent

Being in this study is entirely your choice. You have the right to refuse to participate or to stop taking the survey at any time. Please print a copy of this form for your records.

If you agree to the above information and would like to be in the study, please click on the “I Agree” box below.

I agree

I have read the information above. I agree to participate in this study.

To print a copy of this consent form for your records, please click here