Study Screener

Form Approved

OMB No. 0920-XXX

Expiration Date XX/XX/20XX

ATTACHMENT 7:

STUDY SCREENING INSTRUMENTS

Statement of burden for study screening instruments

Public reporting burden of this collection of information is estimated to average 10 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-XXXX)

Screening Instrument

Formative

African-American Men

Call

ASK TO SPEAK TO A MALE IN THE HOUSEHOLD WHO IS 18-44 YEARS OLD

Introduction

Hello, my name is _______________ and I’m from (name of company). We are calling on behalf of RTI International, a non-profit research organization, and the Centers for Disease Control and Prevention.

We are not selling any product. We are calling to invite men in your area to join in focus group discussions or interviews as part of a research study about HIV testing and prevention. Your opinions are important to us and will contribute to the CDC’s fight against HIV/AIDS.

If you are eligible and choose to be in the group/interview, you will be paid [$50 for interviewer or $100 for group] for your time and effort and to reimburse you for your travel expenses.

To see if you are eligible for this study, we need to ask you some personal questions. There will be some explicit questions about your sexual behavior and HIV. It is your choice to answer these questions. Your answers will be kept private. You can refuse to answer a question or stop at any time.

All of your comments will be kept private. If you are not eligible and/or choose not to be part of the study, all responses you give me today will be destroyed and you will not be contacted again.

My questions will only take a few minutes. May I ask you the questions now?

Yes..................1 Continue

No....................2 End

Procedures for Recording and Limiting Information

Only record information for the questions in the screener. If an informant reveals additional personal information, thank them for being helpful, but guide them back to the screener questions- “That is interesting to learn, but can I know ask you about. . . “

1. Have you ever participated in a focus group session before?

Yes	1
No	2	[SKIP TO Q4]

2. What was/were the topics discussed?

[IF PARTICPATED IN A FOCUS GROUP ABOUT HIV/AIDS IN THE PAST 6 MONTHS, THANK AND END]

3. When was the last time you attended a focus group session?

Less than 6 months ago	1	[THANK AND END]
More than 6 months ago	2

4. What is your gender?

Female	1	[THANK AND END]
Male	2

5. To make sure we are talking with a mix of people from different areas, we are asking for people’s zip codes. Could you tell me your 5-digit zip code?

[RECORD RESPONSE, MUST BE FROM ONE OF THE FOLLOWING ZIP CODES, RECRUIT A MIX.]

City (Select Zips Code for Each Project City)
XXXXX XXXXX XXXXX XXXXX XXXXX	XXXXX XXXXX XXXXX XXXXX XXXXX	XXXXX XXXXX

[NOTE: IF FROM A ZIP CODE OTHER THAN THOSE LISTED, SCREEN AND HOLD FOR POSSIBLE APPROVAL]

6. Do you or does anyone else in your immediate family or household work… [READ LIST.]

In marketing research?	1	[THANK & END]
In marketing or advertising?	2
In public health or healthcare?	3
None	4

7. May I ask if your age is in any of the following categories? Are you . . . [READ LIST]

Under 18 years old	1	[THANK & END]
18 – 24	2	[SEE QUOTA]
25 – 34	3
35 – 44	4
45 years old or older	5	[THANK & END]
Refused	6

8. How would you describe your racial/ethnic background? [READ LIST IF NECESSARY]

American Indian/ Alaska Native……	1	[THANK AND END]
Asian………………………………….	2
African American or Black	3	Continue
Native Hawaiian/ Other Pacific Islander……………………………….	4	[THANK AND END]
White or Caucasian………………….	5
Other	6

9. What is your current marital status? Are you…?

Single	1
Single and in a relationship………….	2
Divorced or Widowed	3
Married	4	[THANK AND END]
Refused	5

10. What is your yearly household income? [READ LIST IF NECESSARY]

Less than $20,000	1
$21,000 to $35,000	2
$36,000 to $45,000	3	[THANK & END]
$46,000 or more	4
Refused	5

11. What is the highest level of education you have completed?

[READ LIST IF NECESSARY]

Primary or Middle School (grade school)	1
Some high school, but not a graduate	2
High school graduate (or GED)	3
Some college/technical, not graduate	4
College graduate or higher	5	[THANK & END]
Refused	6

Now I’m going to ask you a few sensitive questions about your sexual activity and HIV/AIDS. All your answers will be kept confidential.

12. Have you ever had an HIV test?

Yes	1
No	2	[SKIP TO Q. 14]

And when was the last time you had an HIV test? [RECORD DATE]

__________________________

[NOTE: IF PERSON VOLUNTARILY ADMITS TO BEING HIV POSITIVE, THANK AND END]

13. Within the past 12 months, have you had vaginal, oral or anal sex with… [READ AND RECORD ALL THAT APPLY]

A female	1
A male	2	[THANK AND END]
Neither/Have not had sex	3
Refused	4

[NOTE: OKAY TO HAVE HAD SEX WITH A MALE BUT MUST HAVE HAD SEX WITH A FEMALE WITHIN PAST 12 MONTHS TO QUALIFY]

14. Within the past 12 months, have you had unprotected sex? By “unprotected sex” we mean having sex without a condom.

Yes	1
No or refused	2	[THANK AND END]

15. Within the past 12 months, have you had sex with more than 1 partner?

Yes	1	[CONTINUE]
No	2	[THANK AND END]

Focus Group Invitation:

As I mentioned earlier, we are holding a casual discussion about HIV/AIDS and we would like to include your opinions. The focus group discussion session will last about 2 hours. You will not be asked to buy anything. You will be contacted at a later date to remind you of the group. Any information that you provide to us will be kept confidential. We're simply interested in your opinions.

16. For participating in the session, you will be paid $100 and refreshments will be served. Will you be able to join us?

Yes	1	[SKIP TO Q20]
No (Refuse to participate)	2	[THANK AND END]

IDI Invitation:

As I mentioned earlier, we are talking to men about HIV/AIDS and we would like to include your opinions. We would like to invite you to take part in an informal interview session that will last about 1 hour. You will not be asked to buy anything. You will you be contacted at a later date to remind you of the interview. Any information that you provide to us will be kept confidential. We're simply interested in your opinions.

17. For participating in the interview, you will be paid $50. Will you be able to join us for an interview?

Yes	1	[Skip TO Q20]
No (Refuse to participate)	2	[THANK AND END]

Closing for Ineligible Participants:

Thank you for answering all of my questions. You are not eligible to be in this study. There are many possible reasons why people are not eligible for the study. These reasons were decided earlier by the researchers. We value your interest in this research study. Thank you for being willing to help us.

18. [IF “YES” TO EITHER INVITATION, READ THE FOLLOWING STATEMENTS…]

“We will be audiotaping the group/interview and some project staff from CDC may be observing the group/interview. In order to participate in the [group/interview], you must agree to being audiotaped and allowing staff from the CDC to observe. As I said, if you choose to attend, whatever you say will be kept private. In the focus groups, we will ask all other group members to keep what is said private. We will never link your name with any comment you make in the focus group or interview in any report that we write.”

“If you need to wear glasses either for reading or watching TV, please bring them with you to the [group/interview].”

“Also, we need to let you know that there will not be any childcare provided at the facility, so please make the appropriate childcare arrangements if you have children.”

In order for us to send you a reminder letter/email with directions to the group/interview and to call to remind you of your appointment time, I need to ask for your contact information. We will destroy this information after the group/interview is over.

Participant Information

Interviewer: ________

Date: ________

Letter sent: ________

Reconfirmation: ________

Call

NAME: _______________________________________________________

ADDRESS: _________________________________________________

CITY: _________________________________________________

ZIP CODE: _________________________________________________

Phone : Day___________________ Evening ___________________

EMAIL _______________________________________________________

What is the best time to reach you? What is the best telephone number to reach you at that time? If you do not answer, may we leave a private message at that number?

BEST TIME TO BE REACHED: ________________________________________

BEST PHONE NUMBER: __________________

Is there another time and number we can try if we miss you?

ALTERNATE PHONE NUMBER:

Your participation in this study is very important. If for some reason you will not be able to attend, please let us know right away. You can call us anytime at [insert phone number], and if we are not here, please leave a message. You can also call if you have any questions. Thank you.

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