Neighborhood Interview Recruitment and Consent

Form Approved

OMB No. 0920-XXXX

Exp. Date: XX/XX/XXXX

Community Context Matters Study

Attachment 3

Neighborhood Interview Recruitment Script and Informed Consent

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-New)

Neighborhood Interview Recruitment Script and Informed Consent

Hi, my name is (name) and I am an interviewer from NORC at the University of Chicago.

We are doing a brief survey as part of a research study that is being sponsored by the Centers for Disease Control and Prevention (CDC) . We want to learn what people in this community know about a new method for preventing infection with HIV (the virus that causes AIDS).

The survey will take about 20 minutes. We will provide a $20 gift card as a token of thanks for completing this interview.

This survey is being done with a small computer that you can hold in your hand. Through the earphones you will hear the questions and touch the screen to provide your answer. If you decide to participate in the survey, I will walk you through the process and get you started. I will be available to answer any questions you have or help if the system isn’t working correctly.

Some of the questions are personal and may make you feel uncomfortable. However, I will not be looking at your answers as you give them. I will not record your name or any other information that would identify you as an individual. All answers you give to survey questions will be private and cannot be linked to you as a person. Your answers to questions will be collected on a tablet and stored on computers that are protected by passwords and other features that prevent anyone who is not a part of the study team from seeing the information.

Taking this survey is completely voluntary. You are free to decide not to participate. If you decide to participate, you are free to stop answering survey questions at any time for any reason. You can refuse to answer any individual question.

Although this study will not benefit you personally, we hope that our results will help us improve HIV prevention services for your community.

If you have any questions about this study, or feel you have been harmed in any way by participating in this interview, you may contact Ms. Julie Gasparac, 312.759.4297 or gasparac-julie@norc.org.

If you have any questions about your rights as a study participant, you may contact (name, phone, e-mail of chair of the local IRB)

Do you have any questions at this time? Do you want to participate in the survey?

(offer checkbox on ACASI screen to check yes or no)