Focus Group Agreement - Category 1

Appendix 4c

Focus Group Participant Agreement Form

(Name of Project)

Focus Group Participation Agreement Form

Purpose, Participation, and Procedures

This project is funded by the Centers for Disease Control and Prevention (CDC) to look at (1) how (Agency Name) refers clients to HIV prevention and support services and (2) your outcomes from the referrals you receive. The findings may help (Agency Name) improve the way they provide HIV prevention and support services to people in the community in the future.

To participate in the focus group, you must be: 1) living with HIV; and 2) age 13 or older.

The focus group will be a one time, 1.5 hour group discussion of up to 10 HIV-positive individuals. During the focus group, you will be asked to talk about your personal experiences, including experiences with HIV medical care and services you may or may not have used. This focus group will be audio-taped so it can be transcribed by a staff member at (Agency Name). The staff member will not include your name in the written document. Your opinions will be grouped with the opinions from the other focus group participants.

Risks and Discomfort

Information shared during the focus group is personal. All of your opinions will be kept private. Your participation in this project is voluntary. You do not have to answer any questions you do not want to answer and can stop participating in the focus group at any time.

Benefits

There is no direct benefit to you for being in the project, but what we learn from the project may help (Agency Name) improve the way they provide HIV prevention and support services to people in the community in the future.

Disclosure of Alternative Treatment

Your participation in this project is voluntary. If you do not want to participate in the focus group, you are still eligible to participate in HIV medical care and other HIV prevention and support services from (Agency Name).

Privacy

The information collected during the focus group is personal and sensitive in nature. The staff at (Agency Name) will:

• Implement strict CDC security requirements, including the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule to ensure security of the data and all information.

• Work with CDC to maintain participant privacy and security standards throughout the project.

• Keep paper copies of files or notes in a locked filing cabinet inside a locked room. Project data will not contain any information that could identify you. In other words, your name will not be connected to your statements and opinions.

• Encrypt data before sending to CDC.

• Submit data to CDC via the Secure Data Network (SDN).

Once electronic data are received by CDC, they will be reviewed for completeness and errors and stored securely.

Tokens of Appreciation

Agency will need to insert information about their tokens of appreciation here.

Contact Information

Agency will need to insert contact information for agency staff here.

Agreement Statement and Signature

Your participation in this project is voluntary. In other words, you decide if you want to participate in this project or not. If you agree to participate and later decide that you no longer want to, you can withdraw from the project at that time.

I agree to participate in the focus group. The staff explained the project, the time needed, and the tokens of appreciation that will be given to me in the project.

___________________________________________ ___________________

Participant Date

___________________________________________ ___________________

Staff Member Date