African American Consent

African American STD Disparities Health Communication Project

ATTACHMENT 1

Consent Form for Online Survey

Reading level 8.9 (assessed by Flesch-Kincaid)

Form Approved

OMB No. 0920-0572

Expiration Date: 2/28/2015

Introduction and Purpose:

You have been asked to take part in a survey as part of a research study. The purpose of the survey is to hear your opinions about sexual health ad concepts. [Insert survey vendor] and RTI International, a nonprofit research organization in North Carolina, are conducting the survey. The study is sponsored by the Centers for Disease Control and Prevention (CDC).

Procedures:

The survey is about sexual health-related ad concepts and should take about 30 minutes to complete.

Risk/Discomforts:

You might feel embarrassed or upset by some questions in this survey. You can decline to answer any questions for any reason. You can stop the survey at any time.

Benefits:

There is no direct benefit to you for taking this survey. However, you may learn more about sexual health, sexually transmitted diseases (STDs), your own risks, and ways to keep yourself safe and protected in your relationships.

Privacy:

Your responses will be kept secure to the extent allowable by law. No identifying information will be included in the survey.

Payment:

We will give points redeemable for merchandise as a token of our appreciation.

Right to Refuse or Withdraw:

It is your choice to do this survey. You can choose not to answer any question. You can stop taking the survey at any time.

Persons to Contact:

If you have questions about the survey, you can call Jennifer Uhrig (RTI) 1-800-334-8571 extension 23311. 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.

Consent:

• I have read this consent form and agree to participate in the survey. [CLICK HERE]

• I have read this consent form and do not want to participate in the survey. [CLICK HERE]