Study Screener

Attachment 5

Study Screener

Form Approved

OMB NO.____

Exp. Date_____

Reading Level of Introduction 6.7 (assessed by Fleish-Kincaid)

We are asking people to be in a research study that will help us learn more about what people think about HIV testing.  RTI, a research company in North Carolina, and Knowledge Networks in California are doing the study. The Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia is funding the research. 

To see if you are a good match for this study, we will need to ask you some personal questions. Some of the questions will be about the types of sex you have and your HIV status, if you know it.  It is your choice to answer the questions. Your answers will be kept private to the extent allowed by law. You can refuse to answer any question or stop at any time. 

May we ask you the questions to see if this you are a good match for this study?

            Yes                       CONTINUE

            No                         TERMINATE

S1. How old are you?

[ENTER NUMBER] _________________

AGE>=18 and AGE<=34 {ELIGIBLE}

S2. What is your sex?

1. Female {ELIGIBLE}

2. Male

8. DON’T KNOW

9. REFUSED

Public reporting burden of this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions and completing the questions. 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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (OMB#).

S3. Are you Hispanic, Latino, or Chicano?

1. Yes

2. No {ELIGIBLE}

8. DON’T KNOW

9. REFUSED

S4. What are all the groups that describe your racial background? You can choose more than one of the following groups.

[READ ALL CATEGORIES AND CODE ALL RESPONSES]

1. Asian

2. American Indian or Alaska Native

3. Black or African American {ELIGIBLE}

3. Native Hawaiian or other Pacific Islander

4. White

5. Other

8. DON’T KNOW
9. REFUSED

S5. Which group best describes how you identify yourself? Choose only one of the following

1. Asian

2. American Indian or Alaska Native

3. Black or African American {ELIGIBLE}

4. Hispanic, Latino, or Chicano

5. Native Hawaiian or other Pacific Islander

6. White

7. Other

8. DON’T KNOW
9. REFUSED

S6. What is the highest grade or year of school you finished?

1. Primary or middle school {ELIGIBLE}

2. Some high school, but not a graduate {ELIGIBLE}

3. High School graduate or GED {ELIGIBLE}

4. Some college or technical school {ELIGIBLE}

5. 4 year college degree or more

S7. Are you now…

1. Married

2. Divorced {ELIGIBLE}

3. Widowed {ELIGIBLE}

4. Separated {ELIGIBLE}

5. Never married {ELIGIBLE}

6. A member of an unmarried couple {ELIGIBLE}

8. DON’T KNOW

9. REFUSED

S8. Have you ever tested positive for HIV?

1. Yes

2. No {ELIGIBLE}

8. DON’T KNOW

9. REFUSED

S9. Do you live in Philadelphia or Cleveland now?

1. Yes

2. No (ELIGIBLE)

[If S9=1 skip to S11]

S10. Have you moved from Philadelphia or Cleveland since [enter date that the campaign launched in Philadelphia and Cleveland]?

1. Yes

2. No (ELIGIBLE)

S11. Within the past 12 months, have you had sex with …

1. A male {ELIGIBLE}

2. A female

3. Both {ELIGIBLE}

4. Neither/have not had sex

S12. In the past 12 months, did you ever, even one time, have sex without a condom?

1. YES {ELIGIBLE}

2. NO

1. DON’T KNOW, NOT SURE {ELIGIBLE}

ELIGIBLE

Reading Level 4.4 (assessed by Fleish-Kincaid)

Thank you very much. You are eligible to take part in our study about HIV Testing. Please click the button below to go to the study consent form.

{GO TO THE CONSENT FORM}

INELIGIBLE

Reading Level 6.7 (assessed by Fleish-Kincaid)

I’m sorry, but you are not a good match for this study. There are many possible reasons why people are not a good match for the study. The reasons were decided earlier by the researchers. If you have questions about HIV/AIDS or how to protect yourself, you can call 1-800-CDC-INFO to get answers to your questions. Thank you for your interest in this study and your willingness to help us. {TERMINATE}