Form 1.

Informed consent Study ID: [____][____][____][____][____][____]

Information sheet for study participant

INvestigation of Services delivered for TB
by External care system – especially the Private sector in Bandung, Indonesia (INSTEP)
1. Introduction
Tuberculosis (TB) remains a leading global public health problem despite considerable efforts
to increase coverage of detection and treatment. Currently, Indonesia is at 2nd rank of high
TB burden countries in the world. Therefore, innovative interventions to control TB disease
are highly needed for Indonesian setting.
TB-HIV research centre is a research group in Faculty of Medicine Universitas Padjadjaran
which conduct a study aimed to investigate TB related services delivered by the private
practitioners and public sectors. In this study, we will kindly ask your opinion about TB
diagnostic, referral and treatment practices among private practitioners in Bandung,
Indonesia.
2. What is the benefit of this study?
This study aimed to explore barriers to implement standard TB diagnostic and treatment in
private practitioners setting. Furthermore, we would like to understand socio-cultural and
economic factors associated with TB diagnostic, referral and treatment practices among
private practitioners.
3. What should I do?
We will ask series of semi-structured questions regarding your opinion about TB care and
management provided by private practitioners.
4. What are possible risks might happen if I join this study?
Ideally, neither risk or harmful effect is concerned in this study. Any information that you
provided to the research team will remain confidential.
5. What if I want to stop my participation in this study?
Participation in this study is fully voluntary. Any time you can withdraw your participation in
this study for any reasons. However, we would be highly appreciated if you can inform the
research team before hand if you would like to discontinue your participation.
6. What are the benefit by joining this study?
We will provide you with full information about current update on TB diagnostic and
treatment from WHO and The International Union against TB and Lung Disease organisation.
The information will be provided in softcopy files.
7. What about confidentiality issue in this study?

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Form 1. Informed consent Study ID: [____][____][____][____][____][____]

To maintain your privacy, we will put your identity anonymous using barcode system. Any
information related to you will be put into register system. Research team can only access
your data through certain username and password.
8. Will I receive certain amount of money for my participation?
No, in this study, we will provide a souvenir for you as a gratitude of your willingness to be
interviewed and also as a compensation of your time.
9. If I have questions, whom should I contact?
Whenever you have questions in this study, please do not hesitate to contact the research
team as follows:
Dr. Bachti Alisjahbana, Ph.D, Sp.PD-KPTI : Phone number: +62-817611099 or +62-22-2030776

Dr. Bony Wiem Lestari, M.Sc : Phone number: +62-8122375633

Dr. Nur Afifah : Phone number: +62-81297579920

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Form 1. Informed consent Study ID: [____][____][____][____][____][____]

Informed Consent for Study Participant

INvestigation of Services delivered for TB
by External care system – especially the Private sector in Bandung, Indonesia (INSTEP)

I have been invited to participate in research about “INvestigation of Services delivered for TB
by External care system – especially the Private sector in Bandung, Indonesia (INSTEP)”. I am
aware that there may be no benefit to me personally. I am given the contact details of the
principal investigator. I have read the foregoing information, or it has been read to me. I have
had the opportunity to ask questions about it and any questions I have been asked and have been
answered to my satisfaction. I consent voluntarily to be a participant in this study and understand
that I have the right to withdraw from this study at any time without affecting me anyway.

Name of participant
Signature of participant

Date (dd/mm/yyyy)

If illiterate 1
I have witnessed the accurate reading of the consent form to the potential participant, and the
individual has had the opportunity to ask questions. I confirm that the individual has given
consent freely.
1 A literate witness must sign (if possible, this person should be selected by the participant and
should have no connection to the research team). Participants who are illiterate should include
their thumb print as well.

Name of participant
Thumbprint of participant

Name of witness

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Form 1. Informed consent Study ID: [____][____][____][____][____][____]

Signature of witness
Date (dd/mm/yyyy)

I have accurately read or witnessed the accurate reading of the consent form to the potential
participant, and the individual has had the opportunity to ask questions. I confirm that the
individual has given consent freely.

Name of health care worker

Signature of health care
worker

Date (dd/mm/yyyy)

A copy of this Informed Consent Form has been provided to the participant.
_____ (initialed by the researcher)