PROMISE: Consent to Be Interviewed Form

PROMISE: Consent to be Interviewed Form

This interview is part of a program being conducted by ______(Agency Name).

The purpose of this interview is to gather information about people’s experiences in trying to reduce their risk of STD/HIV. These experiences can be used to write stories to distribute to peers in order to help them reduce their risk also.

This interview is anonymous. We do not want to know your name or other identifying information. During this interview I will ask you personal questions about your sexual practices and drug use.

The interview will be tape-recorded, so please do not use your name or the names of other people you know while the recorder is turned on.

Only staff participating in this program will listen to the tape recording. In some cases, stories will be written based on the interview, and these stories may be printed—without identifying information—in STD/HIV prevention pamphlets or newspaper stories.

We would like for you to answer all the questions fully, but you may choose not to answer anything you are not comfortable with.

I have been informed about the nature and purpose of this interview. I agree to be interviewed and to participate in this program under the conditions that have been described to me.

______Participant Signature Date

______Staff Signature Date