Persons interviewed with short and Proxy interview

Attachment 2b

Short Questionnaire for Medical Monitoring Project (MMP)

Short Questionnaire for

Medical Monitoring Project (MMP)

VERSION 1

Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC, Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0011). Do not send the completed form to this address.

­­­­­­­­­­­­­­­­

DEPARTMENT OF HEALTH AND HUMAN SERVICES

P

ublic Health Service

Centers for Disease Control and Prevention

Atlanta, GA 30333

2007 MMP Short Questionnaire

Participant ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ __

Site ID Facility ID Respondent ID

Interviewer ID: ___ ___ ___

Population Definition Period (PDP) START date: (__ __/ __ __ / __ __ __ __ )

^{(M M / D D / Y Y Y Y )}

Population Definition Period (PDP) END date: (__ __/ __ __ / __ __ __ )

^{(M M / D D / Y Y Y Y )}

Interview date: (__ __/ __ __ / __ __ __ __ )

^{(M M / D D / Y Y Y Y )}

Interview language: □ 1 English □ 2 Spanish

□ 3 Other (Specify_________________)

T

Note to Reviewer: The QDS version of this interview will be programmed to determine the age of the participant based on the Patient Definition Period Start Date. As described in the protocol, all participants must have been 18 years of age or older on the date written in this area.

ime questionnaire began:  __ __:__ __  □ AM    □ PM

Hour Minute

SAY: “I'd like to thank you for taking part in this survey. Remember that all the information you give me will be confidential and your name will not be recorded anywhere on this paper. To begin, I would like to ask you some questions about your background. The answers to some questions may seem obvious to you, but I need to ask you all of the questions.”

Q1. Have you ever participated in the MMP interview?

No…………………………………………………	 00		Skip to Q2
Yes…………………………………………………	 01
Refused to answer………........................................	 07
Don’t Know………………………………….……	 09		Skip to Q2

Q1a. What month and year did you participate in the MMP interview?

__ __ / __ __ __ __

^{( M M Y Y Y Y )}

[77 = Refused, 99 = Don’t know]

Q1b. Where were you interviewed?

_____________________________________ (City)

_____________________________________ (State)

[77 = Refused, 99 = Don’t know]

Interviewer instructions: If the patient was previously interviewed in a month during which 2006 data collection cycle interviews were conducted, go to Say Box before Q2. Otherwise, skip to Q2.

SAY: “We are only interviewing people this year who haven’t already been interviewed during 2006. Thank you very much for your time.” DISCONTINUE INTERVIEW AND GO TO INTERVIEW COMPLETION MODULE.

Q2. What is your date of birth?

__ __/ __ __ / __ __ __ __

^{(M M / D D / Y Y Y Y )}

Interviewer instructions: If respondent was less than 18 years of age on PDP start date, go to Say Box before Q3; otherwise, skip to Q3.

SAY: “We are only interviewing people who were 18 years or older on _______/ ______ [BEGINNING OF THE PDP]. Thank you very much for your time.” [DISCONTINUE INTERVIEW AND GO TO INTERVIEW COMPLETION MODULE.]

Q3. What was your sex at birth? [CHECK ONLY ONE RESPONSE.] [READ CHOICES EXCEPT “Intersex/ambiguous”.]

Male…………….…………………..………………… 01

Female..………………………………..……………... 02

Intersex/ambiguous……………………………..……. 03

Refused to answer……………………………………. 07

Q3a. Do you consider yourself to be male, female, or transgender? [CHECK ONLY ONE RESPONSE].

Male…………….…………………..……………	 01
Female..………………………………..………...	 02
Transgender…………………………………...…	 03
Refused to answer……………..………………...	 77
Don’t Know………………………………...……	 99

Q4. What is the highest level of education you completed? [CHECK ONLY ONE RESPONSE.] [DON’T READ CHOICES.]

Never Attended School...…………..……………	 01
Grades 1 through 8 ………………………………	 02
Grades 9 through 11.…………..……………….	 03
Grade 12 or GED..………………………………	 04
Some College, Associate’s Degree, or Technical Degree.. ……………………………	 05
Bachelor’s Degree………………....………….…	 06
Any post-graduate studies ..……………………	 07
Refused to answer……………..………………...	 77
Don’t Know………………………………...……	 99

Q5. Do you consider yourself to be Hispanic or Latino/a?

No…………………………………..………..…	 00		Skip to Q6
Yes...…………………………………...……...…	 01
Refused to Answer………………………..…..…	 07		Skip to Q6
Don’t Know. .……...………………………..……	 09

Q5a. What best describes your Hispanic ancestry? [CHECK ALL THAT APPLY.][DON’T READ CHOICES.]

Mexican…………….…..………………………	 01
Puerto Rican………..……………………………	 02
Cuban…………...…………………..……………	 03
Dominican……...………………………………	 04
Other (Specify: _________________)……….……	05
Refused to answer………....……………………	 07
Don't know………………………..……….………	 09

Q6. Which racial group or groups do you consider yourself to be in? You may choose more than one option. [CHECK ALL THAT APPLY.][READ CHOICES.]

Asian…………….…..………………....………..	 01
Black or African American……………..…..……	 02
American Indian or Alaska Native…..…………	 03
Native Hawaiian or other Pacific Islander………	 04
White…………….…..…………….......……...…	 05
Other (Specify: _________________)………..….	 06
Refused to answer………………..………………	 07

Q7. In the past 12 months, have you been homeless at any time? By homeless, I mean you were living on the street, in a shelter, a Single Room Occupancy (SRO) hotel, temporarily staying with friends/family, or living in a car.

No………………….…..………………..……….	 00
Yes…………………………………………..……	 01
Refused to answer………………………………	 07
Don’t Know……………..………………..………	 09

Q8. In the past 12 months, have you had any kind of health insurance or coverage? I am not referring to coverage for medicines only.

N o………………….…………………..………....…... 00 Skip to Q9

Yes………………………………………..…………... 01

R efused to answer………………………….……….… 07

Skip to Q9

Don’t Know…….………………………….……….… 09

Q8a. Was there a time in the past 12 months that you didn’t have any insurance coverage?

No………………….…..………………..……….	 00
Yes…………………………………………..……	 01
Refused to answer………………………………	 07
Don’t Know……………..………………..………	 09

Q9. What are the main ways your prescription medicines for HIV and related illnesses were paid for in the past 12 months? [CHECK ALL THAT APPLY.] [DON’T READ CHOICES.]

	I wasn’t taking any prescription medicines for HIV or related illnesses…………………………..	 01
	Private health care coverage...................................	 02
	I got my HIV medicines at a public clinic….….	 03
	I paid for my HIV medicines myself (“out of pocket”)........................................................................	04
	AIDS Drug Assistance Program (ADAP)……..…	 05
	I participated in a clinical research trial or drug study that provided my medicines…..……………	 06
	An AIDS service organization provided me my medicines................................................................	 07
	Medicaid/Medicare………………………….……	 08
	Other (Specify: __________________________)	 09
	Refused to answer………………………………	 07
	Don’t Know……………..………………..………	 09

Q10. In the past 12 months have you received any form of public assistance or welfare, including Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) [READ CHOICES.]?

No, and I haven’t applied for any ……..……….	 00
No, I applied, but I haven’t received any………..	 01
Yes, I received………………....…………………	 02
Refused to answer………………………….…….	07
Don’t Know…….………………………….…….	 09

SAY: “Now I’m going to ask you some questions about getting tested for HIV and the care that you are receiving for HIV.”

Q11. When did you first test positive for HIV?

__ __/ __ __ __ __

^{(M M / Y Y Y Y )}

[77 = Refused to answer, 99 = Don’t Know]

Interviewer instructions: If date of first HIV positive test is after the PDP end date, confirm the date in Q11. If the date is correct, go to the Say Box before Q12; otherwise, go to Q12

SAY: “We are only interviewing people who tested positive for HIV before _______/ ______ [end of the PDP]. Thank you very much for your time.” [DISCONTINUE INTERVIEW AND GO TO INTERVIEW COMPLETION MODULE.]

Q12. When did you first go to a health care provider for HIV-related care after learning you had HIV?

__ __/ __ __ __ __

^{(M M / Y Y Y Y )}

[77 = Refused to answer, 99 = Don’t Know]

Interviewer instructions: If date of first HIV-related care is after the PDP end date, confirm the date in Q12. If the date is correct, go to the Say Box below; otherwise, skip to instructions before Q13.

SAY: “We are only interviewing people whose first HIV-related care was before _______/ ______ [END OF THE PDP]. Thank you very much for your time.” [DISCONTINUE INTERVIEW AND GO TO INTERVIEW COMPLETION MODULE.]

Interviewer instructions: If response to Q12 (date first went to provider for HIV-related care) is more than 3 months from response to Q11 (date first tested positive for HIV), go to Q13; otherwise, skip to Q14.

Q13. What were the reasons you didn’t go to a health care provider soon after you learned of your HIV infection? [CHECK ALL THAT APPLY.] [DON’T READ CHOICES.]

Felt good, didn’t need to go ………..…………....	 01
Forgot to go……………..……………………..…	 02
Missed my appointment(s)...………..……………	 03
Too busy to go…………...…...…………..………	 04
Moved or out of town…………………..……...…	 05
Didn’t want to think about being HIV positive…..	 06
Didn’t believe test result ………..…………….…	 07
Unable to get transportation …………………..…	 08
Unable to get childcare ……..……..………..……	 09
Inconvenient (location, hours, time, etc.)....……	 10
Didn’t know where to go…………….…………	 11
Hard to find the right doctor or a good doctor for me…………………………………..…	 12
Initial CD4 count and viral load were good…..…	 13
Drinking or using drugs………….…………….....	 14
Living on the street…………………………….....	 15
Didn’t have money …………......………….……	 16
Didn’t have insurance ………....…..………….…	 17
Unable to get earlier appointment…..……….…	 18
Incarcerated…..……………………..……….….	 19
Other (Specify:___________________________)	 20
Refused to answer………………………………	 77
Don’t know ……………..……..…………………	 99

Q14. When did you last go to a health care provider for HIV care?

__ __/ __ __ __ __

^{(M M / Y Y Y Y )}

[77 = Refused to answer, 99 = Don’t Know]

Interviewer instructions: If date last went to provider is more than 3 months prior to interview date, go to Q14a; otherwise, skip to Say Box before Q15.

Q14a. What were the reasons you didn’t go to a health care provider for HIV care during the past 3 months? [CHECK ALL THAT APPLY.] [DON’T READ CHOICES.]

Felt good, didn’t need to go ………..…………....	 01
Forgot to go……………..……………………..…	 02
Missed my appointment(s)...………..……………	 03
Too busy to go…………...…...…………..………	 04
Moved or out of town…………………..……...…	 05
Didn’t want to think about being HIV positive…..	 06
Didn’t believe test result ………..…………….…	 07
Unable to get transportation …………………..…	 08
Unable to get childcare ……..……..………..……	 09
Inconvenient (location, hours, time, etc.)....……	 10
Didn’t know where to go…………….…………	 11
Hard to find the right doctor or a good doctor for me…………………………………..…	 12
Initial CD4 count and viral load were good…..…	 13
Drinking or using drugs………….…………….....	 14
Living on the street…………………………….....	 15
Didn’t have money …………......………….……	 16
Didn’t have insurance ………....…..………….…	 17
Unable to get earlier appointment…..……….…	 18
Incarcerated…..……………………..……….….	 19
Other (Specify:___________________________)	 20
Refused to answer………………………………	 77
Don’t know ……………..……..…………………	 99

SAY: “Now I’m going to ask you some questions about places where you get medical care for HIV. If you don’t remember everything, that’s okay. Tell me what you remember.”

Q15. In the past 12 months, is there one place in particular, like a doctor’s office or clinic, where you usually go for most of your HIV care, like CD4 tests, viral load tests or HIV-related medicines?

No………………….…..………………..……….	 00
Yes…………………………………………..……	 01		Skip to Q15b
Refused to answer………………………………	 07
Don’t Know……………..………………..………	 09		Skip to Q16

Q15a. What are the reasons you don’t have a usual source of care for treatment of HIV?

[CHECK ALL THAT APPLY.] [DON’T READ CHOICES.]

Couldn’t afford a usual source of care…………..	 01
Didn’t know where to find regular HIV care.……	 02
Couldn’t get a regular appointment anywhere…..	 03
No HIV doctors in my area………………………	 04
Didn’t think it was necessary….…………..……..	 05
Thought it was necessary, but never tried to get one……………………………………………….	 06
Didn’t know where to find a regular doctor who speaks the same language as me…………..…….	 07
Have just recently been diagnosed .…………….	 08
Did not feel the need to seek treatment for HIV…	 09
Other (Specify:___________________________)	 10
Refused to answer………………………………..	 77
Don’t know ……………..……..…………………	 99

Interviewer instructions: Skip to Q16

Q15b. What is the name of the place? Remember, this information will be kept private.

Name:

Interviewer instructions: After recording response, go to paper Facility Visits Log and enter location information and additional information for this place. After entering this information, continue with the next question.

Q15c. Did you get HIV medical care at _____________ [THIS PLACE] between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP]?

No………………….…..………………..……….	 00
Yes…………………………………………..……	 01
Refused to answer………………………………	 07
Don’t Know……………..………………..………	 09

Q16. In the past 12 months, have you been to any other doctor’s office or clinic for your HIV care? If you were in jail or prison during the last 12 months, please include those providers as well.

No………………….…..………………..……….	 00	Skip to Q17
Yes…………………………………………..……	 01
Refused to answer………………………………	 07
Don’t Know……………..………………..………	 09	Skip to Q17

Q16a. What is the name of the place?

Name:

Interviewer instructions: After recording response, go to paper Facility Visits Log and enter location information and additional information for this place. After entering this information, continue with the next question.

Q16b. Did you get HIV medical care at _____________ [this place] between _____/_____ [beginning of the PDP] and _______/ ______ [end of the PDP]?

No………………….…..………………..……….	 00
Yes…………………………………………..……	 01
Refused to answer………………………………	 07
Don’t Know……………..………………..………	 09

Q17. During the past 12 months, how many times did you go to an emergency room for HIV

care? (Please don’t include visits related to injuries such as accidents or other types of

injuries).

____ ____

[77=Refused to answer, 99=Don’t Know]

Q18. During the past 12 months, how many times did you go to an urgent care center for HIV care? (Please don’t include visits related to injuries such as accidents or other types of injuries).

____ ____

[77=Refused to answer, 99=Don’t Know]

Q19. During the past 12 months, how many times were you admitted to a hospital because of

an HIV-related illness? (Please don’t include visits that were made only to the Emergency Room.)

____ ____

[77=Refused to answer, 99=Don’t Know]

Interviewer instructions: If Q19 is “0”, skip to Q20.

Q19a. What is the name of the hospital where you were admitted?

Name:

Interviewer instructions: After recording response, go to paper Facility Visits Log and enter location information and additional information for this place. After entering this information, continue with the next question.

Q19b. Were you hospitalized at _____________ [THIS PLACE] between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP]?

No………………….…..………………..……….	 00
Yes…………………………………………..……	 01
Refused to answer………………………………	 07
Don’t Know……………..………………..………	 09

SAY: “Now I’m going to ask some questions about the medicines that you are taking. To begin, I’ll ask about medicines your doctor has prescribed to treat your HIV.

Q20. Have you ever taken any antiretroviral medicines to treat your HIV? These medicines are also known as ART, HAART, or the AIDS cocktail.

No………………….…………………..……  00

Yes………………………………………..……  01 Skip to Q21

Skip to Say Box before Q23

Refused to answer……………………………  07

Don’t Know……………..………………..........  09

Q20a. What are the reasons you have never taken any antiretroviral medicines?

[CHECK ALL THAT APPLY.] [DON’T READ CHOICES.]

Doctor advised to delay treatment…..…………......  01

Recently into medical care/haven’t had time……….  02

CD4 count and/or viral load are good………...........  03

Feel good, don’t need them......……..………………  04

Worried about side effects …..………..…….….......  05

Drinking or using drugs…………..…..…….………  06

Didn’t want to think about being HIV positive.........  07

No money…………….……….…………....……….  08

No insurance………………….…………....……….  09

Worried about ability to adhere/often forget…........  10

Living on the street.…………………………..……..  11

Taking alternative/complimentary medicines...........  12

Other ………………………………………………  13

(Specify:_________________________________)

Refused to answer ………………………………….  77

Don’t know…………………….………………......  99

Interviewer instructions: Skip to Say Box before Q23

Q21. Are you currently taking any antiretroviral medicines to treat your HIV?

No………………….…………………..……  00

Yes………………………………………..……  01 Skip to Say Box before Q23

Skip to Say Box before Q23

Refused to answer……………………………  07

Don’t Know……………..………………..........  09

Q21a. What are the reasons you aren’t currently taking any antiretroviral medicines?

[CHECK ALL THAT APPLY] [DON’T READ CHOICES]

Doctor advised to delay treatment…..……………	 01
Recently into medical care/haven’t had time….…	 02
CD4 count and/or viral load are good…….…......	 03
Feel good, don’t need them......………..…………	 04
Worried about side effects …..……………..…….	 05
Drinking or using drugs…………..…..………..…	 06
Didn’t want to think about being HIV positive....	 07
No money…………….……….…………....……	 08
No insurance………………….…………....……	 09
Worried about ability to adhere/often forget…....	 10
On the street.…………………………..…….…..	 11
Taking alternative/complimentary medicines........	 12
Other (Specify:___________________________)	 13
Refused to answer ……………………………….	 77
Don’t know…………………….………………....	 99

Q22. Have you taken antiretroviral medicines in the past 12 months?

No………………….…..………………..……….	 00
Yes…………………………………………..……	 01
Refused to answer………………………………	 07
Don’t Know……………..………………..………	 09

SAY: “Now I am going to ask you some questions about your need for services related to HIV.”

In the past 12 months, have you needed any of these services: [Show RESPONSE CARD F] [read choices.]

Interviewer instructions: If response to Q23a is “No”, 77 or 99, skip to Q24a; otherwise, go to Q23b. If response to Q23b is “Yes”, 77 or 99, skip to Q24a; otherwise, go to Q23c. Follow the same pattern for Q23-Q36.

	[Needed this service in the past 12 months?]	If “Yes” in Q23a-Q36a, ask: Have you been able to get this service in the past 12 months?	If “No” in Q23b-Q36b, ask: What was the main reason you haven’t been able to get this service?
	CODE: No = 00, Yes = 01, Refused to answer = 77, Don’t Know = 99	CODE: No = 00, Yes = 01, Refused to answer = 77, Don’t Know = 99	See code list below for responses [ENTER ONLY ONE RESPONSE.] [DON’T READ CHOICES.]
Q23. HIV case management services	a. [_____]	b. [_____]	c. [___ ___]
Q24. Mental health counseling	a. [_____]	b. [_____]	c. [___ ___]
Q25. Social services, such as insurance assistance or financial counseling	a. [_____]	b. [_____]	c. [___ ___]
Q26. Assistance in finding a doctor for ongoing medical services	a. [_____]	b. [_____]	c. [___ ___]
Q27. Assistance in finding dental services	a. [_____]	b. [_____]	c. [___ ___]
Q28. Adherence support services	a. [_____]	b. [_____]	c. [___ ___]
Q29. Home health services, such as home nursing care or assistance	a. [_____]	b. [_____]	c. [___ ___]
	[Needed this service in the past 12 months?]	If “Yes” in Q23a-Q36a, ask: Have you been able to get this service in the past 12 months?	If “No” in Q23b-Q36b, ask: What was the main reason you haven’t been able to get this service?
	CODE: No = 00, Yes = 01, Refused to answer = 77, Don’t Know = 99	CODE: No = 00, Yes = 01, Refused to answer = 77, Don’t Know = 99	See code list below for responses [ENTER ONLY ONE RESPONSE.] [DON’T READ CHOICES.]
Q30. Chore or homemaker services (paid or volunteer)	a. [_____]	b. [_____]	c. [___ ___]
Q31. Assistance in finding shelter or housing	a. [_____]	b. [_____]	c. [___ ___]
Q32. Assistance with finding meals or food	a. [_____]	b. [_____]	c. [___ ___]
Q33. Transportation assistance	a. [_____]	b. [_____]	c. [___ ___]
Q34. Childcare services	a. [_____]	b. [_____]	c. [___ ___]
Q35. Education or information on HIV risk reduction	a. [_____]	b. [_____]	c. [___ ___]
Q36. Other (Specify:___________________)	a. [_____]	b. [_____]	c. [___ ___]

For Q23c-Q36c: [ENTER ONLY ONE RESPONSE.][DON’T READ CHOICES.]

1. I don’t know where to go or who to call

2. Did not complete application process

3. The system is too confusing

4. The waiting list is too long

5. It’s not available in my area

6. They charge too much

7. I don’t have the money to pay

8. Transportation problems

9. Language barrier

10. Not Eligible / Denied services

11. I’m too sick to get out

12. Other (Specify)

77. Refused to answer

99. Don’t Know

Time questionnaire ended:  ___ ___:___ ___  □ AM    □ PM

Hour Minute

Interview Completion

END OF INTERVIEW

SAY: “Thank you again for taking part in this survey. Please remember that all the information you have given me will be kept private. ”

Interviewer instructions:

Offer assistance with information and resources, according to local protocol.

If interview was discontinued due to prior interview during the current calendar year OR respondent age < 18, don’t pay the respondent.

If interview was discontinued due to first HIV positive test after the PDP, OR interview was partially/fully completed, pay the respondent and have him/her sign the receipt.

Interviewer: Please enter the following items after completion of the interview.
			PAYMENT VERIFICATION
		C1.	Payment made:
				No……………………………………..………..…….. 00
				Yes ...…………………………………...……...……  01		Skip to C2
		C1a.	Why was payment not made?
				Participant refused payment…………………………... 01		Skip to C3
				O ther…………………………………...……...……… 02		Skip to C3
				(Specify:) ______________________________________
		C2	Receipt signed (or initialed):
				No…………………………………..………..………... 00
				Y es...…………………………………...……...……… 01		Skip to C3
		C2a.	Why was receipt not signed?
				Participant refused to sign..…………………………... 01
				Other…………………………………...……...……… 02
				(Specify:) ______________________________________
		C3. Reason MMP Short Questionnaire was administered:
				Participant is ill…..……...…………………...……….. 01
		Interview required a translator……………………….. 02
		Other…………………………………...……...……. 03
		(Specify:) ______________________________________
		C4. How confident are you of the validity of the respondent’s answers?
				Confident..………….…………………..……….......…01
				Some doubts..................…………………..…………... 02
				Not confident at all............…………………………..... 03
	C5. Record any additional comments, including disruptions that might have taken place during the interview, reason the interview might have been stopped, or why the respondent’s answers may not have been reliable.
________________________________________________________________________________________
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