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Cancer Literacy Measure for African American Women
Survey Informed Consent Form

NAME OF PRINCIPAL INVESTIGATOR: Lydia P. Buki, Ph.D., University of Illinois at Urbana-Champaign, Department of Kinesiology & Community Health

INVESTIGATOR: Jennifer B. Mayfield, M.S., University of Illinois at Urbana-Champaign, Department of Educational Psychology, Counseling Psychology Division

You are invited to participate in a cancer literacy survey. The purpose of the study is the development of a cancer literacy measure for African American women. We hope to learn about African American women’s health issues, such as healthcare access, relationship with healthcare providers, and cancer screening. Before completing the survey, please read the consent form below and click the “Yes” choice and “Next” button at the bottom of the page if you understand the description of the study and consent to participate in the study.

You must be 18 years of age or older in order to participate in the study. If you agree to participate, you will be asked to fill out a background questionnaire and complete a survey about women’s health issues. Your survey responses are anonymous, meaning that we will not collect any identifiable information from you including your name, address, and the IP address of the computer you are using to complete the survey. There are no known risks associated with participating in this study outside of what you may encounter in everyday life when discussing women’s health issues. The possible benefits of this study for you may be to provide you with the opportunity to consider your health needs and to help researchers and healthcare providers learn about African American women’s health issues.

The survey will take approximately 20-30 minutes to complete. After completing the survey, you may choose to be entered into a drawing for one of 10 $25 gift cards to Target. Your contact information cannot be connected to your survey answers, so your answers will remain anonymous even if you choose to enter the lottery.

Your participation in this research is voluntary. You may discontinue participation at any time or skip a question you do not want to answer without any penalties or loss of benefits to which you are otherwise entitled. You may also print a copy of this consent form for your personal records. If you have questions regarding this project, please contact Jennifer Mayfield (jmayfie2@illinois.edu; 773-718-7405) or Dr. Lydia Buki (buki@illinois.edu; 217-265-5491). If you have any questions about your rights as a participant in this study, please contact the University of Illinois Institutional Review Board at 217-333-2670 (collect calls accepted if you identify yourself as a research participant) or via email at irb@illinois.edu.

1. I have read and understood the consent form and voluntarily agree to participate. (Please click “Yes” and “Next” if you agree.)