Venue Brief Intercept Interview

APPENDIX NUMBER 5: Venue Brief Intercept Interview

(administered via handheld computer)

Form Approved

OMB NO. ________

Exp. Date ________

Public reporting burden of this collection of information is estimated to average 2 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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXX)

Clicker ID _________ Community Code ___ ___ Start Time__ __:__ __ am pm

Interviewer ID _________ Venue Code ___ ___ ___ End Time__ __:__ __ am pm

Date __ __/__ __/__ __ (populated by the computer) Site code__________

Hi, I’m working with the [insert local project name] at the [insert university or organization’s name]. This project looks at what may put Black/Latina women at risk for getting HIV and is funded by the Centers for Disease Control and Prevention.

1) Can I ask you a few questions to see if you are eligible to participate in the study?

I won’t ask your name or any questions that can identify you.

___ Yes

___ No

If Q1= no, Interviewer instructions: “Thank the respondent and end the interview”.

Else ask Q2

You can refuse to answer any question or stop this interview at any time. Okay, here we go…

2) How old are you?______ (if respondent is <18 or >59 years of age, Interviewer instructions: “Thank the respondent and end the interview). Else ask Q3

3) Are you Hispanic or Latina?

___ Yes

___ No

If Q3 response = “Refused to answer” ask Q3a, else ask Q4.

Interviewer instructions: “Please give best assessment of the ethnicity of this respondent.”

3a) Does this respondent appear to be Hispanic or Latina?

___ Yes

___ No

4) How would you best describe your racial background?

___ American Indian or Alaska Native

___ Asian

___ Black or African-American

___ Native Hawaiian or Pacific Islander

___ White

___ Refused to answer

If Q4 response = “Refused to answer” ask Q4a, else ask question Q5.

Interviewer instructions: “Please give best assessment of the race of this respondent participant.”

4a) What race would you characterize this respondent as?

___ American Indian or Alaska Native

___ Asian

___ Black or African-American

___ Native Hawaiian or Pacific Islander

___ White

5) Now I need to ask you a few personal questions related to your sexual behavior. Your responses will be kept completely anonymous; I will not ask your name. Is it all right if we continue?

___ Yes

___ No

If Q5 response = no, Interviewer instructions: “Please thank respondent and end the interview.” Else ask Q6

6) Have you had sexual intercourse with a man in the past year? By sexual intercourse, I mean vaginal or anal sex.

___ Yes

___ No

___ Refused

7) Would you be interested in taking part in a women’s study that provides HIV testing?

___ Yes

___ No

___ Refused

Interviewer instructions: “Thank the respondent and end the interview.“

The next question is calculated by the computer..

7) Is the respondent eligible* for the study?

___ Yes

___ No

___ Unknown, incomplete data

Validation: if Q2= age 18-59 and Q3 or Q3a=yes (if site =Miami) OR Q4 or 4a= Black/African-American (if site= Alabama or North Carolina), and Q6= yes and Q7= yes, then eligibility =yes.

If Q2 or either Q3 or Q3a (if site =Miami) OR Q4 or 4a (if site= Alabama or North Carolina) or Q6 or Q7 = refused, then eligibility = unknown, incomplete data.

Else, eligibility= No

*Study eligibility includes:

1. Black (if site =North Carolina or Alabama) or Hispanic(if site= Miami) women

2. 18 to 59 years of age

3. Willingness to be tested for HIV

4. Had vaginal or anal sex with a man in the past 12 months