Form Tab 8 Tab 8 Retention Risk Screener

Tab 8

Retention Risk Screener (Phase 2 Study)

Participant Study ID Number ___ ___ ___ ___ Date ___ ___/ ___ ___ /___ ___ ___ ___

ATTITUDES & BELIEFS

The following items are about your HIV medical care. There are no ‘right’ or ‘wrong’ answers. I simply want your opinion. Please tell me how much you agree or disagree with each of the following statements.

1. I don’t always trust the medical care system to do the right thing for me.

Strongly agree Somewhat agree Somewhat disagree Strongly disagree

2. I don’t always trust my clinic to do the right thing for me.

Strongly agree Somewhat agree Somewhat disagree Strongly disagree

3. I believe it is OK to skip my HIV medical appointments every now and then.

Strongly agree Somewhat agree Somewhat disagree Strongly disagree

4. I sometimes worry that I might be seen in the clinic by someone who doesn't know that I have HIV.

Strongly agree Somewhat agree Somewhat disagree Strongly disagree

5. I do not always need to let the clinic know when I cannot make it to my HIV medical appointment.

Strongly agree Somewhat agree Somewhat disagree Strongly disagree

6. When I am feeling well I do not need to come in for my HIV medical appointments.

Strongly agree Somewhat agree Somewhat disagree Strongly disagree

7. I do not really need to take HIV medicines until I start feeling sick.

Strongly agree Somewhat agree Somewhat disagree Strongly disagree

8. I am worried that taking HIV medicines may make me feel bad.

Strongly agree Somewhat agree Somewhat disagree Strongly disagree

9. In the next 6 months, I will likely keep all of my HIV medical appointments.

Strongly agree Somewhat agree Somewhat disagree Strongly disagree

The following items are about your life in general. Please mark the answer that is closest to your opinion.

10. I have someone I can talk to when times are tough.

Strongly agree Somewhat agree Somewhat disagree Strongly disagree

11. I have someone I can call on for things like transportation, child care, or other things I need.

Strongly agree Somewhat agree Somewhat disagree Strongly disagree

12. In the past 30 days, I have been worried about having enough food for me or my family.

Strongly agree Somewhat agree Somewhat disagree Strongly disagree

13. In the past 30 days, I have been worried about having enough money.

Strongly agree Somewhat agree Somewhat disagree Strongly disagree

Now I will read through a list of reasons why a person might miss an HIV-related medical care appointment.

NEW patient script: Please answer “YES” or NO” if any of the following are reasons that you think MIGHT cause you to miss an HIV medical care appointment.

ESTABLISHED patient script: Please answer “YES” or NO” if any of the following are reasons why you HAVE MISSED an HIV medical care appointment in the past 3 months.

14. Trouble getting an HIV medical care appointment at a time that was convenient for you

Yes No

15. Problems getting someone to answer the phone when you called to schedule an HIV medical appointment

Yes No

16. Problems making appointments for HIV medical care because you did not have a telephone

Yes No

17. Putting other needs (such as food or housing) ahead of your HIV medical care

Yes No

18. Problems arranging childcare

Yes No

19. Having to take care of someone else

Yes No

20. Transportation problems

Yes No

21. Could not take time off of work

Yes No

22. Forgot about your HIV medical care appointment
Yes No

The next 3 questions are about where you have stayed or lived in the past 3 months.

23. In the past 3 months, at how many different places have you lived?

1 2 3 or more

24. Where are you currently staying or living?

In my own home or apartment

In someone else’s (friend, relative, etc.) home or apartment

Some other type of living arrangement (e.g., multiple people’s homes/moving from house to house, hotel/motel, shelter, residential treatment program, boarding house, group home, halfway house, on the streets/in a car/park/abandoned building)

25. During the past 3 months, have you been incarcerated (in jail or prison) for at least 48 hours?

Yes No

The following questions are about recent drug or alcohol use. I would like to remind you that your responses will be kept confidential. You may refuse to answer any item.

26. In the past 30 days, have you injected drugs (e.g. injected heroin or cocaine)?

Yes No

Interviewer: Please read each drug category in bold; use the examples in italics as probes, if needed. Be sure that the participant knows that all of these are drugs which are not injected.

27. In the past 30 days, have you used the following drugs?

a. Crack (rock, gravel) Yes No

b. Powder cocaine (snort, blow) Yes No

c. Heroin, not injected (horse, smack, tar) Yes No

d. Methamphetamines (meth, crystal meth, speed, Yes No

crank, ice)

e. Marijuana or hashish (pot, weed) Yes No

f. Prescription painkillers without a prescription (Codeine, Yes No

Morphine, Demerol, Darvon, Oxycontin, Vicodin, Dilaudid)

28. In the past 30 days, have you had 5 or more alcoholic drinks (beer, wine, or hard liquor) in 1 day?

Yes No

The last 3 questions are about feelings or emotions you might have had in the past 3 months.

29. During the past 3 months, did you feel so sad, alone, angry, or anxious that you were not able to do your regular daily activities?

Yes No

30. During the past 3 months, did you feel the need to talk to someone like a counselor or social worker because you felt sad, alone, angry, or anxious?

Yes No

31. Did you talk to someone like a counselor or social worker about your sadness, loneliness, anger, or anxiety in the past 3 months?

Yes No