Consent To Participate In An Interview For A Research Study

Attachment 5: Consent form

CONSENT TO PARTICIPATE IN AN INTERVIEW FOR A RESEARCH STUDY

(Please print a copy of this page for your records)

What is this about?

In many states, pharmacies are legally allowed to sell non-prescription syringes. We are creating resources to help pharmacy personnel sell non-prescription syringes. This includes training for pharmacy personnel and toolkits, with components to make injecting safer. As part of creating these resources we want to test out the training with people who work in pharmacies. As part of this study, you will complete an online survey about non-prescription syringe sales, use the online training for about a week, and one week later take another online survey about non-prescription syringe sales to see if the training had an impact.

Who are we?

We are from dfusion, a small business that uses technology to create programs to improve the health of youth and adults. We have many years of experience developing health education programs, particularly for vulnerable populations and creating trainings for health professionals. This project is funded through a contract from the Centers for Disease Control (CDC).

What will I be asked to do?

As part of the study you will be asked to do three things: 1) Take an online survey. You will be asked a series of questions, including questions about your race and gender, and questions about your knowledge of and experiences with non-prescription syringe sales; 2) Take an online training where you watch short videos about non-prescription syringe sales; 3) About one week after completing the training you will be asked to take another online survey with questions very like the first survey. After you finish the second survey you will be emailed a $20 gift card as a thank you for your participation.

Are there any risks?

You might feel uncomfortable answering some of the questions, particularly those that involve your employer. We will keep the information you share with us confidential. No information will be shared with your employer, your manager or coworkers, any professional organization that you belong to, or other person not involved with the study. We won’t link your name or any identifiable information about you to the surveys.

Do I have to take part?

You can choose whether or not to take part. You do not have to answer any questions if you do not want to. Your participation will not positively or negatively impact your employment and pharmacy staff will not be told who did or did not participate. If you decide you do not want to take part after you have started the survey simply stop taking the survey and close the survey window. No record of your answers will be saved if you stop before the end.

What are the benefits of taking part?

There are no direct benefits to you for participating in the study. By taking part in this project you will help us to make resources, including the online training, to assist pharmacy personnel who choose to participate in non-prescription syringe sales, and better understand if those resources had an impact. The goal of the resources is to reduce the spread of HIV and hepatitis by using sterile injection equipment along with education. We hope that you enjoy participating and taking the online training, and you may learn skills that will help you in your work.

What if I have questions?

If you have questions about the study, you can call the study directors:

• Regina Firpo-Triplett, Principal Investigator: 831-222-5094; regina.firpo@dfusioninc.com

• Tamara Kuhn, Principal Investigator: 831-222-5103; tamara.kuhn@dfusioninc.com

For questions about your rights as a participant in this research project call:

• Dr. Tanya Matthews, IRB Chairperson: (866) 537-5030. An IRB is a committee that helps to make sure people in research projects are protected.

We can’t guarantee the confidentiality of information sent by email.

How do I give consent to take part?

We need your consent before you can take part in the study. Your consent allows you to take part. Please indicate your decision by clicking the YES button below, completing your name/signature, and then clicking the submit button. You can only participate if you answer “YES”.

Thank you.

If you wish to participate, please select the YES box:

• YES—I agree to take part in the study.

If you checked YES, please fill in your name and date below.

Name (signature):_________________________________ Date:__________

Email address: __________________________________ Phone:__________

We will use your email address to send you links to the online training, study surveys and a $20 gift card for study participation. We can’t guarantee the confidentiality of information sent by email.

SUBMIT

After submission, the user will automatically proceed to the survey.