Consent Form – Delphi Survey Participants

Project Title: Exploring the Feasibility of Using Predictive Models to Determine the Risk of Falling out of HIV Care.

This study has been approved by the University of the Witwatersrand. The ethics reference number is:

I hereby consent to take part in the above-named research project. acknowledge that:

1. I have read and understand the participant information sheet and have been given the opportunity to ask questions about my involvement in the project with the researcher.

2. My participation is voluntary, and I am free to withdraw at any time without giving a reason and without there being any negative consequences. Furthermore, I am free to decline answering any specific question or questions.

3. My anonymous responses are to be used during the Delphi process. I understand that my name will not be linked with research materials during the Delphi process or in the results of the research.

I consent to:

☐ Participating in two rounds of a Delphi survey

I consent for my data and information provided to be used in this research project for an extended period of time.

☐ I understand that my involvement is confidential and that the information gained during the study may be published and stored for other research use but no information about me will be used in any way that reveals my identity.

☐ I understand that taking part in this study will not affect my relationship with the researcher or the University of Witwatersrand, now or in the future.

Signed:

Name:

Date: