Form 1 Study to Assess Hepatitis Risk (STAHR): Screener Form

:

Study to Assess Hepatitis Risk

Attachment 3

Eligibility Screener

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?

1. 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

2. 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).

3. Is this the first time you are participating in the STAHR study?

• Yes

• No

• Don’t Know

• Refuse to answer

4. 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

4. Have you seen one of our flyers? [Hand them a flyer to read]

• No

• Yes

• Don’t Know

• Refuse to Answer

4. 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)

4. 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 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

11. Let’s see, that makes you how old? _______

• Don’t Know

• Refuse to Answer

12. I’m sorry, what year did you say you were born?

• Don’t Know

• Refuse to Answer

13. 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 month?

• 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. How many needle exchanges have you used?

• One

• Two

• Three

• More than three

• 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. What race do you consider yourself to be? (Check all that apply)

• Asian

• Black or African American

• American Indian or Alaska Native

• Native Hawaiian or Other Pacific Islander

• White

• Other

• Hispanic

• Refuse to Answer

19. What is your sex? Or what sex do you consider yourself to be?

• Male

• Female

• Transgender

• Refuse to Answer

20. 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.

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