Attachment 15 - OMBpassback Clean Eligibility Screener

Transgender HIV Behavioral Survey

Attachment 3A

Data Collection Instrument: Eligibility Screener

Form Approved:

OMB No: 0920-XXXX

Expiration Date: MM/DD/YYYY

Transgender HIV Behavioral Survey: Eligibility Screener

____________________________________________________

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).

AUTO1 Survey Version: THBS-Pilot Version MM/DD/YYYY

AUTO2 Date of Interview: __ __/ __ __ / __ __ __ __ AUTO3 Time Begin __ __:__ __  AM  PM

^{(M M / D D / Y Y Y Y )}

INT1. Interviewer ID __ __

INT2. City __ __

INT3. Survey ID ___ ___ ___ ___

INT4. Field Site ID ___ ___ ___ ___

INT5. Interviewer: Is the participant a seed?

No………………….……………….………….. 0 Yes….……………………………….……......... 1

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. If selected, I’ll turn the computer over to you so you can complete the survey on your own.

IF RESPONDENT IS A SEED (INT5=1) then skip to E2

ES1. Which of the following describes how you know the person who gave you this coupon? You can choose more than one answer. [Read choices. Check all that apply.]

A friend ……...................................................................  1

A sex partner, girlfriend/boyfriend, husband/wife......  2

A relative or family member…………………...............  3

A co-worker…………………………………………….  4

A person you use drugs with…………………...............  5

A person you buy drugs from…………………..............  6

A person you share needles with…………………......... 7

An acquaintance (that is, a person you know,

but do not consider friend).………..... 8

You don’t know the person/just met them (a stranger)… 9

Refused to answer……………………………………… .R

A

If ES2 is (.R, .D) then skip to Auto5

ge Assessment

ES2. What is your date of birth?

__ __ / __ __ / __ __ __ __

[Refused = .R, Don't know = .D] ^{(M M / D D / Y Y Y Y )}

If AGE < 15 then skip to Auto5

AUTO4 AGE: ES2 - AUTO2/365.25

E

IF ES2a = No, go back to ES2; If Auto4<15 then skip to Auto5

S2a. So, you are [AGE] years old. Is that correct?

No………………….……………….…………..  0

Yes….……………………………….…….........  1

ES3. During 2008, did you already complete any 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………………………..……..  .R

Don't know.……………..………………..........  .D

Ethnic Assessment

ES4. Do you consider yourself to be Hispanic or Latino?

If ES4 is (0, .R, .D) then skip to ES5

No………………….……………………………  0 Yes……………………………………………… 1

Refused to answer………………………………  .R

Don't know……………..……………………...  .D

ES4a. What best describes your Hispanic or Latino ancestry?

[Check all that apply.]

Mexican…………….…..………………………  1

Puerto Rican………..…………………………...  2

Cuban…………...…………………..…………..  3

Dominican……...…………………..…………..  4

Other (Specify_________________)…………...  5

Refused to answer………....……………………  .R

Don't know………………………..…………….  .D

Racial Assessment

ES5. 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

Refused to answer………………………………  .R

Don't know………………………..…………….  .D

ES6. What county do you currently live in? _______________________________________

(Responses in computer program will include all eligible counties from participating MSA)

Other…………………………………………. 66

(Specify___________________________________)

If ES6 =”Other” then skip to ES7

ES6a. How long have you been living in [say project area]?

Months __ __

Years __ __

[Refused = .R, Don't know =.D]

Gender Assessment

ES7. What was your physical sex assigned at birth? [Check only one]

Male…...………………………………………..  1

Female…....…....………………………………..  2

Intersex…………..………....…………………..  3

Refused to answer………....…………………… .R

Don't know……………..……………………...  .D

ES8. Do you consider yourself to be male, female, or transgender? [Check only one]

Male…………………………………………….. 1

Female …………………………………………. 2

Transgender ……………………………………. 3

Other ……………………………………………. 4

(Specify___________________________________)

Refused to answer………………………………  .R

Don't know……………..……………………...  .D

If ES7 is (2, 3, .R, .D) then skip to Auto5

If ES7 is (1) and ES8 is (2, 3) then skip to ES10

ES9. In the past 12 months, have you ever lived as a woman? By living as a woman, I mean dressing and presenting yourself as a woman.

No ………….………………………  0

Yes ……………………  1

Refused to answer………………………………  .R

Don’t know………………………………  .D

N

SAY: I would like to ask you about some people you know personally. By “know personally”, I mean they know you and you know them.

etwork Size Assessment

ES10. About how many people do you know personally who were born male but identify, live, act, or consider themselves to be a woman and who are 15 years of age, live in [project area], and who you’ve seen in the past 30 days?

INTERVIEWER: USE FLASHCARD A

[Refused= .R, Don’t Know= .D] ___ ___ ___

If ES10 is (0, .R, or .D) and ES8 is (1) and ES9 is (0, .R, .D) then skip to INT6

If ES10 is (0, .R, or .D) and ES8 is (1) and ES9 is (1) then skip to INT7

If ES10 is (0, .R, or .D) and ES8 is (2, 3) then skip to INT7

ES10a. Of these [insert number from ES10] persons that you have seen in the past 30 days how many are Latino or Hispanic?

[Refused= .R, Don’t Know= .D] ___ ___ ___

SAY: What is the race of these [insert number from ES10] persons that you have seen in the past 30 days? That is how many are:

ES10b. African American or Black;: [Refused= .R, Don’t Know= .D] ___ ___ ___

ES10c. American Indian or Alaska Native: [Refused= .R, Don’t Know=.D] ___ ___ ___

ES10d. Asian: [Refused= .R, Don’t Know= .D] ___ ___ ___

ES10e. Native Hawaiian or Other Pacific Islander: [Refused= .R, Don’t Know= .D] ___ ___ ___

ES10f. White: [Refused= .R, Don’t Know= .D] ___ ___ ___

If ES8 is (1) and ES9 is (1) then skip to INT7

If ES8 is (2, 3) then skip to INT7

Interviewer Assessment

INT6 Interviewer: Does this person meet the protocol definition of transgender?

No……………………………………………. 0

Yes, identifies or has a feminine presentation…. 1

Yes, other reason……………………. 2

(Specify___________________________________)

Ability to Participate Assessment

INT7. Interviewer: Is this person alert and able to complete the health survey in English?

If INT7 =1 then skip to Auto5

No……………………………………………. 0

Yes……………………………………………. 1

INT7a. Interviewer: Why is the person unable to participate in the health survey?

Language Barrier …………………………. 1

(Specify___________________________________)

Not alert …………………………. 2

Other…………………………………………. 3

(Specify___________________________________)

Eligibility Assessment Section

AUTO5 ELIGIBLE = (calculated using the following eligibility assessment logic)

AUTO6 Time Eligibility Screener Ended __ __:__ __  AM  PM

If Participant NOT ELIGIBLE for THBS

SAY: 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.

I

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

In the survey, the terms “transgender” and “gender-variant” are used broadly to refer to persons who identify, live, or present as a gender other than the one associated with their physical sex at birth. The purpose of the survey is to learn more about risks for HIV among transgender and gender-variant persons. Let me tell you more about it.

Interviewer: Read consent (see appendix H for model consent).

f Participant IS ELIGIBLE for THBS

CONSENT. Interviewer: Did the participant provide consent to participate in the survey?

No.............................................................. 0

Yes............................................................. 1

SAY: Now I will turn the computer over to you to complete the rest of the interview. If you have questions during the survey or need assistance I will be close by to answer your question and provide help.