Provider info sheet and consent

Form Approved

OMB No. 0920-0840

Expiration date: 02/29/2016

“Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment”

3a. Provider Information Sheet and 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 D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-0840)

Provider Information Sheet and Consent Form

Understanding Barriers and Facilitators Experienced by HIV Care Providers

PROVIDER INFORMATION SHEET AND CONSENT FORM

Introduction and purpose

The Centers for Disease Control and Prevention (CDC) has funded Atlas Research and Abt Associates to conduct a voluntary study about barriers and facilitators experienced by HIV care providers when attempting to engage and retain people living with HIV (PLWH) in care. This study highlights CDC’s ongoing efforts to strengthen the delivery of services for PLWH.

What we are doing

As part of this study, we are interviewing providers who deliver HIV care in both public and private healthcare facilities in Atlanta, GA; Baltimore, MD; and Washington, DC. Interview questions will focus on patient engagement, retention, and referral. We will also ask you to complete a brief demographic questionnaire.

Your participation

We are inviting you to voluntarily participate in a one hour interview about your experiences as an HIV care provider and to complete the demographic questionnaire. We are also asking you to give us permission to audio-record the interview. If you do not give your permission to audio-record the interview, we can take written notes during the interview.

Please understand that your participation is voluntary. Your decision on whether or not to participate will not affect your position or employment status in any way. If you do agree to participate, you may stop the interview at any time without penalty.

Privacy

We have developed data security procedures to keep the information collected for this study private. All identifying information will be kept in locked cabinets and on restricted password protected computers and only accessed by authorized study personnel and will not be shared with your employer.

As part of these procedures, we will ask that you do not include individual names or locations in your interview responses. All recordings from the interview will be transcribed by project team members and redacted for sensitive information to the best of our ability. The redacted transcripts will be provided to CDC. The data from the demographic questionnaire will be reported only as aggregate data and will not be submitted to CDC at any point. The data will be used to prepare a final report to CDC and may be reported in manuscripts or conference presentations as feasible. At the end of the contract, all interview recordings and notes will be destroyed.

The records from your participation may be reviewed by people responsible for making sure that research is done properly, including members of Abt Associates’ Institutional Review Board (IRB). All of these individuals are required to keep your identity private. Recordings will be transcribed, redacted to the best of our ability, and provided to CDC. The data will be used by CDC for research purposes only. The reports will disclose the city and type of facility, but all other information will be redacted.

Risks/discomfort

We do not anticipate any immediate risk from your participation in this study. It should be noted though that there is always a small risk of breach of privacy should the data be lost or stolen and that, given the relatively small number of HIV providers within each facility, it is possible that your data could be re-identifiable; however, the procedures mentioned in the privacy section are in place to reduce these risks. These data will only be used for research purposes. The risks associated with participation in this study are no greater than those encountered in daily life.

Benefits

There are no benefits or monetary incentives to you for participating in this study. However, your answers may provide us with information that could be used to develop new strategies and interventions to improve HIV treatment and care in the United States. We will also provide a summary of the study findings to your facility as it may be helpful in future program planning.

Cost

There are no costs to you for taking part in this study.

Who to contact if you have been harmed or have any concerns

This research has been approved by the Institutional Review Board of Abt Associates. If you have any questions about the study please contact the Principal Investigator, Dr. Jamie Hart, at jhart@atlasresearch.us or 404-946-6378, or the co-Principal Investigator, Dr. Cynthia Klein, at 404-946-6310 or Cynthia_Klein@abtassoc.com. If you have questions about your rights as a research participant or questions, concerns or complaints this study, you can contact Katie Speanburg with the Abt Associates IRB at 1-877-520-6835. You will receive a copy of this consent for your records.

Statement of Agreement to Participate in the Research Study (answer yes/no)

Do you agree with the conditions described to voluntarily participate in this study? _________

______________________________

Interviewer’s Name (Printed)

______________________________ ______________________________

Interviewer’s Signature Date Time