Appendix A Example Informed Consent Form
IRB STUDY #XXXXXXXXXX
WEBER STATE UNIVERSITY INFORMED CONSENT
Title of the Research Study
Barriers and Concerns Related to Health Disparities in the African American Community in Utah
Purpose of the Research Study
The study is based on findings that show health disparities in African American communities compared to other minority groups and Caucasians remain high. This research explores why certain healthcare facilities and resources remain underutilized. We want to find out about your experiences and opinions. You are being asked to participate in this study because you are of African American descent.
Number of People Taking Part in the Research Study
If you agree to participate, you will be one of 18 subjects who will be participating in this research.
Procedures for the Research Study
If you decide to be in this research study, you will be asked to sign this consent form after you have had all your questions answered and understand what your participation in the study involves. If you agree to participate and are eligible, you will be part of a discussion (focus) group. The discussion group will last about 60 minutes. The focus group leader will ask you to talk about your experiences and opinions about healthcare-related issues. The focus group will be audio-recorded so we can collect everyone’s ideas. Audio recordings and transcripts of the tapes will remain confidential. They may also remain anonymous if you choose to use a pseudonym (a substitute for your real name) during the discussion group. A brief survey will be handed out after the focus groups to gather some useful demographics. To remain anonymous the participants will use their pseudonyms.
Risks of Taking Part in the Research Study
The risk of participating is that you may feel discomfort when answering personal questions. Your healthcare information will be discussed openly in a group setting. The moderator of the focus group will be trained to keep the group conversation on track with the questions being asked. There will be no direct questions asked about specific healthcare problems. The questions will focus more on general experiences and perspectives. You will choose how much information to disclose during the discussion. You will be asked to sign the consent form. After the focus group has concluded, you must agree not to talk about any healthcare information that others might disclose during the focus group.
Benefits of Taking Part in the Research Study
The benefits will be getting your voice heard so that the researchers can better understand the barriers and concerns for African Americans regarding health care. Healthcare disparities in African American communities have been consistently growing throughout the nation, and this research study hopes to understand why.
Alternatives to Taking Part in the Research Study
You may decline participation in the focus group and research study.
Costs/Compensation for Injury
The cost is about an hour of your time. You will receive an incentive for your participation at the start of the focus group. The compensation will be provided by the Project Success Coalition and will be valued at no more than $25.
Confidentiality
Efforts will be made to keep your personal information confidential. While you may choose to disclose your name during the focus group, the transcripts of audio recordings will use pseudonyms (a substitute for your real name). Even so, we cannot guarantee absolute confidentiality. Your personal information may be disclosed if required by law. Your identity will be held in confidence in reports in which the study may be published.
Contacts for Questions or Problems
For questions about the study, contact the primary researcher, Dr. Monica Williams at [phone number] or .
For questions about your rights as a research participant, or to discuss problems, complaints, or concerns about a research study, or to obtain information, or offer input, contact the Chair of the IRB Committee at [IRB email address].
Voluntary Nature of the Research Study
Taking part in this study is voluntary. You may choose not to take part or may leave the study at any time. Leaving the study will not result in any penalty or loss of benefits to which you are entitled. Your decision whether or not to participate in this study will not affect your current or future relations with Weber State University or Project Success Coalition.
Consent to Participate
In consideration of all of the above, I give my consent to participate in this research study. If I so desire, I will be given a copy of this informed consent document to keep for my records.
Subject’s Printed Name:
Subject’s Signature:
Date:
Printed Name of Person Obtaining Consent:
Signature of Person Obtaining Consent:
Date:
