:
Study to Assess Hepatitis Risk
Attachment 3
Eligibility Screener
02/02/09
Form Approved:
OMB #: 0920-XXXX
Expiration Date
STAHR Screener
Screening ID: ________________
(This number will be generated by QDS)
Staff ID: ___________________
Date of screening data collected: (mm/dd/yyyy) _______________
To begin, may I ask you some questions to determine if you are eligible for the STAHR study?
Have you ever talked with someone about being in this study before Have you ever been screened for this study before?
Yes
No
Don’t Know
Refuse to answer
DO NOT READ: If yes, why are they being screened again?
Never been screened before
Screened, not eligible at that time
Screened, eligible, missed baseline appointment
Don’t Know
How did you hear about the study? (Check all that apply)
a- Recruitment Coupon
b- Needle Exchange/ (specify location:)________________________________________
c- STD Clinic/ (specify location)____________________________________________
d- From a Relative/Friend/Acquaintance
e- Flyer/poster
f- Drug Treatment Program/ Name: ___________________________________________
g- Outreach Worker
h- Other study/ Name of other study: __________________________________________
i- Other /Place: ___________________________________________________________
Don’t Know
Refuse to answer
Public reporting burden of this collection of information is estimated to average 5 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 Information Collections Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (XXXXXXXX).
Is this the first time you are participating in the STAHR study?
Yes
No
Don’t Know
Refuse to answer
Are you taking part in any other studies? (Only indicate “yes” if respondent is taking part in other HIV or hepatitis C longitudinal studies at this time.)
Yes
No (Skip to 4)
Don’t Know (Skip to 4)
Refuse to answer (Skip to 4)
3a. What is the name of study you are currently taking part in?
__________________________________________________________________
Don’t Know
Refuse to Answer
Have you seen one of our flyers? [Hand them a flyer to read]
No
Yes
Don’t Know
Refuse to Answer
Did a staff person (outreach worker) from our project talk to you about the study or hand you a flyer?
No (Skip to 7)
Yes
Don’t Know(Skip to 7)
Refuse to Answer (Skip to 7)
What cross streets were you near at the time you heard of the study or saw a flyer?
______________________________________________________________________________
7. Do you currently live in San Diego?
No
Yes
Don’t Know
Refuse to Answer
8. Have you ever snorted cocaine, speed, meth or heroin?
No (Skip to 9)
Yes
Don’t Know (Skip to 9)
Refuse to Answer (Skip to 9)
7a. How old were you when you first started snorting?
______________________
Don’t Know
Refuse to Answer
7b. What year was that?
Year ________________
Don’t Know
Refuse to Answer
9. Have you ever participated in a drug treatment program (i.e. NA or other twelve step programs, VA, or Stepping Stone)?
No (Skip to 10)
Yes
Don’t Know (Skip to 10)
Refuse to Answer (Skip to 10)
9a. How old were you when you started the most recent drug treatment program? _________
Don’t Know
Refuse to Answer
9b. What year was that? _________
Don’t Know
Refuse to Answer
10. What is your full birth date?
Year: ____________
Month: __________
Day: ____________
Don’t Know
Refuse to Answer
DO NOT READ: Was this person’s birth date verified by picture ID?
Yes – positive ID
No – Questionable ID
No
Let’s see, that makes you how old? _______
Don’t Know
Refuse to Answer
I’m sorry, what year did you say you were born?
Don’t Know
Refuse to Answer
Have you ever injected drugs not prescribed to you by your doctor?
No (Skip to 14)
Yes
Don’t Know(Skip to 14)
Refuse to Answer(Skip to 14)
13a. How old were you the first time you injected? _________
Don’t Know
Refuse to Answer
13b. When did you last inject?
Year: __________
Month: _________
Don’t Know
Refuse to Answer
DO NOT READ: Did this person inject in the last 6 months?
Yes
No
14. Have you ever used a needle exchange?
No (Skip to15)
Yes
Don’t Know (Skip to 15)
Refuse to Answer (Skip to 15)
14a. Have you ever used a needle exchange program in San Diego to get clean needles and syringes?
Yes
No
Don’t Know
Refuse to Answer
15. Are you currently in school?
No
Yes
Don’t Know
Refuse to Answer
16. Do you have a high school diploma or equivalency?
No
Yes
Don’t Know
Refuse to Answer
17. What part of town do you live in or stay in?
______________________________________________________________________________
Don’t Know
Refuse to Answer
18. Do you consider yourself to be Hispanic or Latino/a?
No
Yes
Don’t Know
Refuse to Answer
18. Which of the following best describes your ethnicity? (Check all that apply)
__ Mexican
__
Central American
__
South American
__
Puerto Rican
__
Cuban
__ Dominican
__
Refuse to Answer
19. How would you describe your racial background? (Check all that
apply)
__ Asian
__
Black or African American
__
American Indian or Alaska Native
__
Native Hawaiian or Pacific Islander
__
White
__ Refuse to Answer
20. What is your sex? Or what sex do you consider yourself to be?
Male
Female
Transgender
Refuse to Answer
21. As part of this study, you’ll be asked to have a small amount (about 1.5 tablespoons) of blood drawn for hepatitis C testing. Would you be willing to have this blood drawn and tested?
Yes
No
Don’t Know
Refuse to Answer
Can you please wait a moment while I determine your eligibility?
DO NOT READ:
Is this person between 18-30 years old? Yes______ No______
Report injection drug use in the last 6 months? Yes______ No______
Current resident of San Diego? Yes______ No______
Agree to have blood drawn? Yes______ No______
Agree to provide contact information? Yes______ No______
First time participating in study? Yes______ No______
Check if eligible or ineligible. (Eligible if all answers are YES; Ineligible if they answer NO to any question except for “Agree to provide contact information”)
INELIGIBLE: I want to thank you for talking to me, but, unfortunately, you are not eligible to participate in the study at this time. [Thank the screened individual for their time and offer condoms and other resources that are available.]
ELIGIBLE: Great! You’re eligible to participate in the study. What I would like to do now is have you review and sign a consent form so we can enroll you into the study.
File Type | application/msword |
File Title | Study to Assess Hepatitis Risk |
Author | vbs6 |
Last Modified By | Petunia L. Gissendaner |
File Modified | 2009-02-05 |
File Created | 2009-01-29 |