Key Participant Information Sheet and Consent Form

Form Approved

OMB No.: 0920-0840

Expiration date: 02/29/2016

“Local Effectiveness Assessment Project (LEAP): A Case Study of a Local Jurisdiction Providing HIV Services to MSM”

3. Key Participant 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)

Key Participant Information Sheet and Consent Form

Providing HIV Services to MSM

KEY PARTICIPANT 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 providing HIV services to MSM. This study highlights CDC’s ongoing efforts to strengthen HIV prevention efforts for men who have sex with men (MSM).

What we are doing

As part of this study, we are interviewing key participants who provide HIV prevention and treatment services in both public and private organizations and agencies in Philadelphia, PA. Interview questions will focus on services and benefits provided; accomplishments; and issues in HIV prevention for MSM.

Your participation

We are inviting you to voluntarily participate in a one hour interview about your experiences as a key participant in the HIV community and to complete the demographic questionnaire. The questionnaire includes sensitive questions such as HIV status and sexual orientation. Please note that we are collecting this personal information about everyone to make sure we get a wide range of people and their experiences.

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. You can skip any questions.

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.

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 and demographic questionnaires will be assigned a unique participant study ID and organization ID. The redacted transcripts and data from the demographic questionnaires will be provided to CDC in electronic datasets. The data from the demographic data will be reported only as aggregate data. 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. The data will be used by CDC for research purposes only. The reports will disclose the city and type of organization, 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 participants within each organization, 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 direct benefits to your 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 for MSM 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.

Token of Appreciation. For your participation in the study you will be provided with $40 as a token of appreciation.

 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 (IRB) of Abt Associates. If you have any questions about the study please contact the Principal Investigator, Dr. Jamie Hart, at jhart@atlasresearch.us or 202-717-8716, 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

• Please confirm that you are 18 years of age or older