NHBS Eligibility Screener

Eligibility Screener

National HIV Behavioral Surveillance System: Eligibility Screener
AUTO1. NHBS Round ___ ___

AUTO2. NHBS Cycle ____ (1=MSM; 2=IDU; 3=HET)

AUTO3 Date of Interview: __ __/ __ __ / __ __ __ __

AUTO4. Time Begin

(M M / D

D /

Y

Y

INT1.

Interviewer ID

__ __

INT2.

Enter City

__ __

Y

__ __:__ __

1AM

2PM

Y)

FOR NHBS-MSM, ENTER INFORMATION FOR INT3-INT9,
THEN SKIP TO SAY BOX BEFORE ES1
INT3.

Interviewer: Is this a Same Day Interview or an Other Day Appointment?
Same Day Interview…………..

1

Go to INT4

Other Day Appointment………

2

Go to INT7

Same Day Interview
INT4.

Survey ID

___ ___ ___ ___

INT5.

Venue ID

___ ___ ___ ___

INT6.

Event Number ___ ___ ___ ___

Skip to Say Box before ES1

Other Day Appointment
INT7. Enter the Survey ID from respondent's appointment card. (If unknown, ask your field
supervisor for a new Survey ID number.)
___ ___ ___ ___

INT8. Enter the Venue ID number from the respondent's appointment card. (If unknown, refer to
the Recruitment Events List.)
___ ___ ___ ___

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Eligibility Screener

INT9. Enter the Event Number from the respondent's appointment card. (If unknown, refer to the
Recruitment Events List.)
___ ___ ___ ___
Skip to Say Box before ES1

FOR NHBS-IDU AND NHBS-HET, ENTER
INFORMATION FOR INT10-INT12
INT10. Survey ID

___ ___ ___ ___

INT11. Field Site ID ___ ___ ___ ___

INT12. Interviewer: Is the participant a seed?
No………………….……………….…………..

0

Yes….……………………………….…….........

1

______________________________________________________
FOR ALL NHBS CYCLES
SAY: I’d like to thank you again for your interest in this health survey. Remember that all
information you give me will be kept private and I will not ask for your name. First, I
will ask you a few questions about yourself and then the computer will determine if you
have been selected to participate in the health survey.
ES1.

What is your date of birth?
__ __/ __ __ / __ __ __ __
[Refused = 77/7777, Don't know = 99/9999]

(M

M / D

D /

Y

Y

Y

Y)

Confirmation Message: So, you are [insert calculated age]
years old. Is that correct?
If Respondent is under 18 years old:
Interviewer: Thank you for answering these questions. Unfortunately, the computer has not selected
you to participate in the health survey. Thank you again for your time.

NHBS Data Collection Instrument
July 2007

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Eligibility Screener

ES2.

ES3.

During 20xx, did you already complete at least part of the health survey that [Insert Project
Name] is conducting? It could have been here or at another location.
No………………….……………….…………..

0

Yes….……………………………….…….........

1

Refused to answer………………………..……..

7

Don't know.……………..………………..........

9

Do you consider yourself to be Hispanic or Latino/a?
No………………….……………………………

0

Yes………………………………………………

1

Refused to answer………………………………

7

Don't know……………..……………………...

9

Skip to ES4

Skip to ES4

ES3a. What best describes your Hispanic or Latino ancestry?
[CHECK ALL THAT APPLY.]

ES4.

Mexican…………….…..………………………

1

Puerto Rican………..…………………………...

2

Cuban…………...…………………..…………..

3

Dominican……...…………………..…………..

4

Other (Specify_________________)…………...

5

Refused to answer………....……………………

7

Don't know………………………..…………….

9

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

1

Asian ..……………………..……………….......

2

Black or African American ……………..……..

3

Native Hawaiian or Other Pacific Islander……...

4

White ……………..…………………………….

5

Some other race (Specify________)……...……

6

Refused to answer………………………………

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Eligibility Screener

ES5.

What county do you currently live in?_________________________________________
(List of eligible counties on computer)
IF “OTHER” COUNTY CHOSEN SPECIFY, THEN SKIP TO ES6.

ES 5a. How long have you been living in [say project area]?
Months __ __
Years __ __
[Refused = 77, Don't know = 99]

FOR NHBS-MSM, SKIP TO ES8
FOR NHBS-IDU, SKIP TO ES9
FOR NHBS-HET, ASK ES6 - ES7b, THEN SKIP TO ES9
ES6.

What zip code do you live in?
[Refused = 77777, Don't know = 99999]

ES7.

__ __ __ __ __

SHOW RESPONDENT THE MAP (example provided at end of this document)
Please take a look at this map. Can you point to the area where you live?
Interviewer: Enter area #_____________
(Refused= 77777, Don't know= 99999)

ES7a. IF RESPONDENT IS A SEED (INT12=1)
Interviewer: Does participant live in a Target High Risk Area?
No …………………………………………………

0

Yes ………………………………………………...

1

ES7b. IF RESPONDENT IS NOT A SEED (INT12=0)
Interviewer: Does participant live in a High Risk Area?
No ………………………………………………….

0

Yes …………………………………………………

1

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Eligibility Screener

FOR NHBS-MSM
ES8.

What was your sex at birth? [CHECK ONLY ONE]
Male…...………………………………………..

1

Female…....…....………………………………..

2

Intersex/ambiguous………....…………………..

3

Refused to answer………....……………………

7

Don't know……………..……………………...

9

FOR ALL NHBS CYCLES
ES9.

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

1

Female ………………………………………….

2

Transgender …………………………………….

3

Refused to answer………………………………

7

Don't know……………..……………………...

9

FOR NHBS-MSM, SKIP TO ES19;
FOR NHBS-HET, SKIP TO SAY BOX
BEFORE ES18

FOR NHBS-IDU, ASK ES10 - ES17b, THEN SKIP TO ES19
ES10. Have you ever in your life shot up or injected any drugs other than those prescribed for you?
By shooting up, I mean anytime you might have used drugs with a needle, either by
mainlining, skin popping, or muscling.
No………………….……………………………

0

Yes………………………………………………

1

Refused to answer………………………………

7

Don't know……………..……………………...

9

NHBS Data Collection Instrument
July 2007

Skip to ES17
Skip to ES17

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Eligibility Screener

ES11. When was the last time you injected any drug? That is, how many days or months or years
ago did you last inject?
[Interviewer: If respondent answers today, enter “000” in # of Days field]
# of Days:

__ __ __

# of Months: __ __ __
# of Years:

__ __ __

[Refused = 777, Don't know = 999]
ES12. Which drug do you inject most often?
[READ CHOICES. CHECK ONLY ONE]
Heroin………………………… ……………..

1

Cocaine…………………………………………

2

Speedball – Heroin and cocaine together …….

3

Crack…………………………………………..

4

Crystal, meth, tina, crank, ice……………………...

5

Something else (Specify_________________)…

6

Refused to answer………....……………………

7

Don't know………………………..……………

9

ES13. Where on your body do you usually inject? [CHECK ALL THAT APPLY]
(Have participant show ALL injection areas on body. Check for physical signs of injection)
Fresh track marks………………………………

1

Needle-sized scabs……………………………..

2

Abscesses……………………………..……….

3

Old track marks or scars...……………………..

4

Injects in covered area ...……………………….

5

No physical signs...……………………………..

6

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July 2007

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Eligibility Screener

ES14. Step-by-step, tell me how you prepare your drugs.
INTERVIEWER:
Description could include:
Mix water or lemon juice/vinegar
Cooker /Heat drugs
Filter
Description OK…………………………………

1

Description Not OK…………………………….

2

ES15. Step-by-step, tell me how you inject your drugs.
INTERVIEWER:
Description could include:
Tie off and find vein (IVDU)
Clean injection site
Register (IVDU)
Description OK………………………………

1

Description Not OK…………………………..

2

ES16. What type of syringe do you usually inject with?
INTERVIEWER:
Description could include:
Syringe size (in cc’s or units)
Needle size (gauge, length)
Cap (color, number)
(Can also ask where they usually get syringes, what they do with
them after injecting, and how they know if they are new or used)
Description OK………………………………

1

Description Not OK…………………………..

2

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July 2007

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Eligibility Screener

ES17. Have you ever used drugs that you did not inject, other than those prescribed for you?
No………………….……………………………

0

Yes………………………………………………

1

Refused to answer………………………………

7

Don't know……………..……………………...

9

Skip to ES19
Skip to ES19

ES17a. When was the last time you used any drugs that you did not inject?
[DO NOT read choices]
Within the last month (30 days) ………………

1

More than a month ago but within the last year..

2

More than a year ago……………………………

3

Refused to answer………....……………………

7

Don't know………………………..……………

9

ES17b. Which drug do you use most often that you do not inject?
[READ CHOICES. CHECK ONLY ONE]
Marijuana……………………… ……………..

1

Heroin …………………………………………

2

Cocaine…………………………………. …….

3

Crack…………………………………………..

4

Crystal, meth, tina, crank, ice……………………...

5

Something else (Specify_________________)..

6

Refused to answer………....……………………

7

Don't know………………………..……………

9

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July 2007

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Eligibility Screener

FOR NHBS-HET, READ SAY BOX BELOW AND ASK ES18

SAY: The next question is about having sex. Please remember your answers will be kept private.
"Having sex" means vaginal sex - penis in the vagina; or anal sex - penis in the anus (butt).

ES18. Have you had vaginal or anal sex with a [insert “man” if respondent is female; insert
“woman” if respondent is male] in the past 12 months?
Yes……………………………………………...

1

No………………………………………………

2

Refused to answer………....……………………

7

Don't know………………………..……………

9

FOR ALL NHBS CYCLES
ES19. Interviewer: Is this person alert and able to complete the health survey in English
or Spanish?
No…………………………………………….

0

Yes…………………………………………….

1

End 1 . If the participant IS NOT ELIGIBLE:
Thank you for answering these questions. Unfortunately, the computer has not selected you to
participate in the health survey. Thank you again for your time.
End Interview.

End 2. If the participant IS ELIGIBLE (Do not disclose why the participant qualifies):

SAY: Congratulations! The computer has selected you
to participate in the health survey. Let me tell you about it.

Proceed to Consent

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Eligibility Screener

CONSENT1. Interviewer: Indicate each activity the participant consents to.
CHECK ALL THAT APPLY.
Taking part in the survey.....................................

1

HIV counseling and testing.................................

2

Having other lab tests (if offered) .......................

3

Storing a blood specimen for future testing.........

4

Declined participation..........................................

5

NHBS-HET MAP Example for use with Seed Eligibility screener:

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July 2007

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