Att 8_Informed Consent Form

Formative Research to Develop HIV Social Marketing Campaigns for Healthcare Providers

Attachment 8: Informed Consent Form

Consent Form

Formative Research for the Development of CDC’s Social Marketing Campaign for Healthcare ProvidersLet’s Stop HIV Together

Introduction and Purpose:

You have been asked to take part in a one-on-one interview as part of a study. The purpose of the interview is to learn about your [current practices related to HIV prevention, testing and care; to get your feedback on current recommendations and guidelines; and to hear your thoughts on materials being developed for healthcare providers as part of CDC’s campaignLet’s Stop HIV Together ]. What we learn from these interviews will be used to inform the development and/or revision of materials for healthcare providers who deliver care to people with HIV or who are at risk of getting HIV. ___________________ (insert contractor name and description) is conducting the interview. The interview is sponsored by the Centers for Disease Control and Prevention (CDC).

Procedures:

During the interview, we will ask you about [tailor based on exploratory, message, concept or material testing]. The interview, including a brief, web-based survey, will take about 1 hour and 15 minutes. We will be interviewing about 582 healthcare providers in the U.S..

In addition to the interviewer, there will be another staff member taking notes. CDC staff working on this project may also observe or listen to the interview.

Before the interview, you will be asked to complete a survey. Your name will not go on this survey. The survey will contain some general questions about your practice and your patient population.

Risks:/Discomforts

The questions we ask are not meant to be sensitive. Still, there is a chance that you may feel discomfort about some of the questions we ask. During both the interview and survey, you may choose not to answer any question you wish or end your participation at any time. We do not know of any other risks related to taking part in this study.

Benefits:

There is no direct benefit to you from being in this interview. However, you may be exposed to educational materials that are designed to serve as resources to share with patients and for healthcare providers to use in their day to day practice. You may find the discussion interesting and informative. What we learn from the interviews will help us to develop materials and to make improvements to them at different stages of development.

Privacy:

We will be audio recording the interview. Digital files from audio recordings will be kept on a password-protected computer, accessible only by authorized staff. Notes will be made of the audio recordings. We will keep the records for reference if needed to confirm the notes. We will only refer to people by their first name in the notes. Your comments will be kept private to the extent allowable by law. The notes and survey data will also be kept on a password-protected computer. Only authorized project staff will be able to see them. Any forms related to the project that have your name or information that could identify you will be kept in a locked file cabinet or on a password protected computer separated from the data. These forms will be destroyed after the interview ends. However, there is still a small risk that your privacy could be broken.

[Also, any information that the [recruitment firm/local facility] already has about you -- because you have been in other projects -- will still be kept there. You may be contacted by them to be in other projects in the future. If you have not been contacted by this [recruitment firm/facility] before this project, they will not keep any of your contact information.

Token of Appreciation:

We will give you [INSERT AMOUNT] as a token of appreciation.

Right to Refuse or Withdraw:

It is your choice to take part in this interview. You can choose not to talk about any topic. You can end the interview at any time for any reason.

Persons to Contact:

If you have questions about the interview, you can call ____________________ (insert contractor name and contact information). S/he 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 [INSERT’s] Office of Research Protection toll-free at [INSERT NUMBER].

Your Consent:

I have read this consent form.I was given I had a chance to ask questions and my questions were answered. the opportunity to keep a hardcopy of this consent form.

[ ]I agree to be in the interview.

[ ] I do not agree to be in the interview.

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