Key Stateholder Informed Consent

Form Approved

OMB No. 0920-XXXX

Exp. Date: XX/XX/XXXX

Community Context Matters Study

Attachment 5

Key Stakeholder 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)

Key Stakeholder 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 organizations involved in HIV prevention in this community know about a new method for preventing HIV infection.

The survey will take about 20 minutes. We are not offering you any money or gifts to take this survey.

[if ACASI]

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.

[If CAPI]

This survey is being done with a small computer that I will hold in my hand. I will ask you the questions and enter your answers directly onto the computer.

I will not record your name or any other information that would identify you as an individual or your organization specifically. All answers you give to survey questions will be private and cannot be linked to you as a person or to your organization.

Taking this survey is completely voluntary and will not affect your job in any way. 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 or your organization directly, 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? (Yes or No)

Do you want to participate in the survey?

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