Form no number no number Eligibility Screener

Attachment 3a

Multi-Site HIV Testing in Mental Health Settings: Eligibility Screener

February 3, 2021

Form approved

OMB no. 0920-xxxx

Expiration date xx/xx/20xx

Multi-Site HIV Testing in

Mental Health Settings: Eligibility Screener

Public reporting burden of this collection of information is estimated to average 1 minute 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. CDC may not conduct or sponsor, and a person is not required to respond to a collection of information unless a currently valid OMB control is displayed. 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 Date of Interview: __ __/ __ __ / __ __ __ __ AUTO2. Time Begin __ __:__ __

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

INT1. Interviewer ID __ __

INT2. Enter City __ __

INT3. Enter Site __ __

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.

INT4. 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 <18 years old, skip to End1

INT5. Do you consider yourself to be Hispanic or Latino/a?

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

Refused to answer………………………………  77

Don't know……………..……………………...  99

INT6. 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…………………………….… 77

Don't know……………..……………………….. 99

INT7. Do you consider yourself to be male, female, or transgender? [CHECK ONLY ONE]

Male…………………………………………….. 1

Female …………………………………………. 2

Transgender (Female to Male)…………………. 3

Transgender (Male to Female)…………………. 4

Refused to answer………………………………  77

Don't know……………..……………………...  99

Ability to Participate Assessment

INT8. Interviewer: Is this person alert and able to complete the health survey in English?

If INT8 =1 then skip to End1

No……………………………………………. 0

Yes……………………………………………. 1

INT8a. 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

AUTO3 ELIGIBLE = (calculated using the following eligibility assessment logic)

AUTO4 Time Eligibility Screener Ended __ __:__ __  AM  PM

END1: If Participant NOT ELIGIBLE for survey:

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.

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