BP Adult Age 16+ Informed Consent Form
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  • TSU S.H.A.P.E. Initiative Bruthas Project

    Purpose of Study: The TSU SHAPE Initiative Bruthas Project is a service-based health program. It provides program participants with health-related services to include sexual health and substance use/dependence screening, individual and/or group-level health education, case management, health service navigation, and community-based referrals. The purpose of this study is to assess health behaviors, the effectiveness of the program's health services, participant service delivery satisfaction (screening, behavioral health counseling, education, and referrals), and the provision of health and community resources.

    Procedure: Participants enrolled into the TSU SHAPE Initiative Bruthas Project will complete an initial 25-minute Minority AIDS Initiative (MAI) assessment where you will be asked a series of demographic (i.e., sexual orientation, housing status, income, etc and behavioral (sexuality, alcohol, drug use, social support, and environment) questions. Based on assessment results, you will learn about your sexual and/or substance use/dependence risk levels and receive appropriate service/peer navigation and community-based referrals. You will also be contacted within 30 days of enrollment to complete a follow-up that assesses demographic, behavioral, and referral updates. Additional services participants may select include the following:

    Sexual Health Screening: Participants (aged 16+) may receive on-site screening for one or more of the following: HIV, Hep-C, Chlamydia, Gonorrhea, and Syphilis. For rapid HIV, Hep-C, and Syphilis, a blood sample is required with preliminary results provided. For Chlamydia and/or Gonorrhea screening, a urine sample must be provided which is lab-processed with results provided accordingly. Participants who are at-risk and/or test positive for HIV, Hepatitis and/or STIs will be immediately provided with education and resources as well as linked with case management and preferred treatment services. The purpose of conducting sexual health screenings is to increase the number of people who know their status and

    Bruthas Intensive Intervention: Up to ten percent of enrolled participants (aged 16+) may be eligible to enroll into the Bruthas Project intensive one-on-one evidence-based intervention. Participants in the intensive evidence-based intervention will complete a 45-minute computer administered orientation assessment and commit to four (4) pre-scheduled 90-minute sessions with a trained service provider to establish behavioral goals and demonstrate progress toward reaching those goals. The intervention concludes with a 45-minute exit interview. All intensive education participants will be linked with and receive case management support while completing the intensive educational intervention. The purpose of the Bruthas intensive intervention is to provide participants with sustained support for maximizing preventive health behaviors.

    Group Education Session: Participants (13+) can enroll into one of the program's 60-minute small-group education sessions delivered by a trained facilitator over a variety of topics (i.e., HIV, Hep-C, substance use, healthy relationships, etc designed to increase preventative health knowledge and practices. For each small group session, the first and last five minutes will be used for participants to complete a true/false pre and post assessment as based on the group topic. The purpose of each session is to assess knowledge and skills gained in reference to the topic presented.

    Case Management: Participants (aged 13+) with chronic and/or complex needs may receive case management services for additional support, navigation, and referrals. The purpose of case management services is to support resource identification and individual skills enhancement through longer-term service planning and implementation for a variety of needs as based on a social determinants of health framework.

    Community Promise for High Impact Prevention (HIP) Role Model: Participants (aged 13+) with personal experiences around HIV, Hep-C, STIs, substance use, or a similarly related health area may opt to participate in a one-time interview about their experience to be featured in one of the TSU SHAPE Initiative Community PROMISE publications. During the interview, a staff member will ask a series of open-ended questions about participant demographics, health behaviors, goals, motivations for reducing risk(s), and steps taken to enhance positive outcomes as a result of behavior change. Interviews will be recorded on audiotape, transcribed for analyses, and assessed for appropriateness of distribution. The interview will take approximately 1.5-2 hours to complete. If participant's interview is selected for publication, participants will have the opportunity to confirm privacy options(Option 1: actual name/photo orOption 2: pseudonym/stock photo) and provide feedback on the final publicationdraft at least 2-weeks before it is submitted for distribution.

    Bruthas Peer Ambassador: Participants may elect to join the TSU SHAPE Initiative as a Peer Ambassador (aged 13+) who is trained to support program operations by delivering health prevention information within the community and supporting outreach efforts. Ambassadors commit to completing a 2-hour introductory training and volunteering 3-4 hours per week and/or three outreach events per month.

    At the end of the initial enrollment and/or each service, participants will also be asked to complete a brief satisfaction questionnaire about services obtained. Data collected will be entered into a password-protected database.

    Voluntariness and Confidentiality: Initial enrollment into the TSI SHAPE Initiative Bruthas Project is voluntary. Participants may elect to receive none, or one or more additional services offered and may withdraw participation at any time, without consequence to you, and your status in the community and/or at Texas Southern University. We are committed to protecting your privacy and information collected in this study will remain confidential with consents in a locked file in the TSI office (Public Affairs Building, 302Q) or in an electronic password protected database. Participant date will be coded with an ID number, a six-digit combination that is kept separate from your consent form and used for tracking follow-ups and confidential reporting per grantor requirements.

    Per state and federal regulations (Texas Family Code § 32.003; 42 C.F.R. § 59.5(a4) 42 U.S.C. § 300(a, minors (16-17 years old) can consent to their own diagnosis and treatment of STIs, examination/treatment of chemical addiction and counseling for suicide prevention, chemical addiction, or sexual, physical, emotional abuse. Minors aged 15 years old or younger will be referred to a Title X clinic for confidential sexual health services.

    The TSU SHAPE Initiative has been awarded a Certificate of Confidentiality by the funders of this study, the Substance Abuse Mental Health Services Administration (SAMHSA). This certificate ensures that information collected cannot be disclosed through subpoena or any local, state, or federal court legal proceeding. However, information about reportable infections, suspected or actual cases of child or elder abuse/neglect, and/or danger of harm to self or others can be disclosed to law enforcement or medical professionals per state law.

    Risk/Benefits: The risks of participating in this study are less than minimal. However, you may experience some discomfort as participants will be asked personal questions about sexual behaviors, alcohol, and drug use. Results from HIV, Hepatitis tests or substance abuse screenings might also cause discomfort. Should you experience any emotional and/or physical discomfort, you are invited to contact the Texas Southern University Counseling Center at (713) 313-7804, the Texas Southern University Health Center at (713) 313-7173, or the Crisis Intervention Hotline at (713) 468-5463 for service support. Additional emotional support and/or referrals can also be obtained by making an appointment for a free visit with the TSU SHAPE Initiative Social Work Case Manager by phone at (713) 313-7426 or by email TSUSHAPEINITIATIVE@tsu.edu. A copy of the Informed Consent will be given to you so that you have a copy of this information for your records.

    Direct benefits of participating in this study include access to free health and social support services. Additionally, results from this study will contribute to learning the extent of community-based sexual and behavioral health service needs and how the TSU SHAPE Initiative can continue to enhance education, testing and treatment needs in the areas of HIV/AIDS, Hepatitis, substance use/dependence, and health

    Incentives for Participation: The incentives for participating in the study include free screening and testing services, as well as brief counseling, health education, referrals, and case management services. Participants may also receive wearable incentives, such as a health-themed bracelet, bag, or t-shirt, as available.

    Contact Information: If you have any questions about participation in this study, please contact Dr. Dominique Guinn, Principal Investigator of this study at (713) 313-7584 or by email at Dominique.Guinn@tsu.edu.

    I acknowledge that (1) this study has been explained to me, (2) I volunteer to take part in this research, (3) I have had a chance to ask questions, (4) If I have questions later about the research, I can ask one of the researcher(s) listed above, (5) If I have questions about my rights as a research subject, I can call the Texas Southern University Committee for the Protection of Human Subjects at (713) 313-4301 or go to http://www.tsu.edu/research, (6) I represent and warrant that if I volunteer to be a Community Promise for HIP Role Model that I have the right to assign my rights and that my story is original, not copied from any other work, will not infringe the rights of any third party, and will be free and clear from any claim by any third party, and (7) I am hereby assigning and granting to the TSU SHAPE Initiative Community PROMISE publication, and their respective successors, an irrevocable, perpetual, non-exclusive, worldwide royalty-free license to reproduce, distribute, publish, create derivative works, and publicly display, with the right to sublicense and assign such rights in a Community Promise for HIP Role Model publication.

    By signing below, I agree to enroll into the TSU SHAPE Initiative Bruthas Project by completing the 25-minute initial assessment. I may choose none or one or more of additional services offered to include 1) a sexual health screening, 2) Bruthas intensive intervention, 3) small group education session, 4) case management, 5) Community Promise for HIP role model, and/or 6) Bruthas Project Peer Ambassador. I also understand a TSU SHAPE Initiative staff member will contact me for service scheduling and follow-ups as needed while actively enrolled in the study.

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  • STI Screening Appointments 

    Public Affairs Building Wing 302N or 302P

    713-313-7558 or 1975

     

  • ATTENTION: Service walk-ins may be accepted; however, sessions are subject to availability, due to existing appointments and/or planned events scheduled, walk-ins may not always be seen the same day. To confirm walk-in availability, please complete this form and then call 713-313-7558. If staff appove walk-in they will make an appointment and you will see that appointment in your calendar invite with information given.

  • A TSU S.H.A.P.E. Initiative staff member will contact you to confirm your submission.

    Press "Submit" below and you will be taken to an initial assessment to be completed BEFORE your visit.

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