Thank you for your interest in The Combine Study. To see whether you may be a candidate for this study, we need to ask you for some information about yourself.  But first, let me tell you about this screening interview and what we will do with your information.
    1. This screening interview will take about 5 minutes. 
    2. You can also stop the screening interview at any time. This is completely voluntary.
    3. We can send you an information sheet about this screening, along with the screening questions, if you would like. We will also give you a form you can send in later if you change your mind and want us to remove your information from our records.
    4. We will ask you about your demographic background, sexual behavior, and history of HIV testing and will record this information in a database containing information from others who have also shown interest in the study. 
    5. This information will only be used for the research study you are interested in.
    6. The only risk to you in this online screening is a potential loss of privacy. However, your privacy is very important to us and we will be very careful with your information. 
    7. Your health information that identifies you is your “protected health information” or “PHI.” We will use your PHI to screen you for our research study. 
    8. The PHI we will use includes your HIV testing history.
    9. To protect your PHI, we will follow federal and state privacy laws, including the Health Insurance Portability and Accountability Act (called HIPAA or “the Privacy Rule” for short).  
    10. The following persons or groups may use and/or disclose your PHI for this study: 
      • The Principal Investigator and the research staff
      • National Institutes of Health, who funds this Research, and people or companies they use to carry out the study
      • Emory offices who are part of the Human Research Participant Protection Program
      • Any government agencies who regulate the research including the Office of Human Subjects Research Protections
    11. We will disclose your PHI when required to do so by law in the case of reporting child abuse or elder abuse.  
    12. You may revoke your authorization at any time by calling the principal investigator, Jeb Jones.
    13. If identifiers (like your name, address, and telephone number) are removed from your PHI, then the remaining information will not be subject to the Privacy Rules. This means that the information may be used or disclosed with other people or organizations, and/or for other purposes.
    14. We do not intend to share your PHI with other groups who do not have to follow the Privacy Rule, but if we did, then they could use or disclose your PHI to others without your authorization. Let me know if you have questions about this.   
    15. Your authorization will not expire because your PHI will need to be kept indefinitely for research purposes.
    16. We can send you a copy of this information, if you would like.

By completing and submitting this screening form, you acknowledge and consent to BuildClinical’s access to the information provided. This includes all data collected on the form, which may be used by BuildClinical to support clinical assessments, facilitate care coordination, and improve services. Your data will be handled in accordance with applicable privacy laws and regulations to ensure its protection and confidentiality.

Do you agree to participate in the screening process, and authorize the use and disclosure of your protected health information as described above?

Yes
No

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