Evaluation of Pharmacy Syringe Access Linked to HIV Testing for Injection Drug Users in New York City (Pharm-HIV) - Pharmacy Telephone Screening and Enrollment Form

FORM APPROVED

OMB. NO. 0920-09XX

EXPIRES XX/XX/XXXX

“Evaluation of Pharmacy Syringe Access Linked to HIV Testing for Injection Drug Users in New York City (Pharm-HIV)”

Pharmacy Telephone Screening and Enrollment Form

Public reporting burden of this collection of information is estimated to average 10 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 persons 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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: PRA (0920-09XX)

_____________________________________________________________________________________

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Centers for Disease Control and Prevention

Atlanta, Georgia 30333

PHARMACY TELEPHONE SCREENING AND ENROLLMENT FORM

Pharm-HIV STUDY

Phone number: _____-_____-_______ Interviewer: ___________________

Pharmacy name: _________________________________________________________

Address:________________________________________________________________

_____________________________________________ ZIP CODE:______________

Call #	Date	Time	Comments / callback day and time
1
2
3
4
5

Hello, could I speak with the managing or supervising pharmacist please?

BUSY/NOT AVAILABLE

Is there a better time I can reach them?

Can I call in the evening or on a weekend? [If callback time is given, record in comments column]

WHAT IS THIS REGARDING?

My name is ________ and I’m with the New York Academy of Medicine. We’re calling to tell you about a research program to provide information on drug treatment and social/medical services to your syringe customers.

I DON’T THINK HE/SHE’D BE INTERESTED

Is there a better time to call?

[SPEAKING TO PHARMACIST]

[INTERVIEWER] if you have already explained the study, skip to question about registration]

Hello, my name is ________. I’m with the New York Academy of Medicine We’re conducting a study involving non-prescription syringe customers at ESAP registered pharmacies. I’m calling to see if your pharmacy is eligible for our study.

So first, are you registered for ESAP? [PROBE” Just a reminder, ESAP is a state law permitting the purchase of up to ten syringes without a prescription. The law is intended to reduce infectious disease transmission from injection drug use.]

IF NO – Would you be interested in registering for ESAP in the future. [If yes, provide with information on how to register, if no, thank them for their time and end the call.]

IF YES- Can I ask you a few questions to see if your pharmacy is elegible? (Probe: it will only take about 3 minutes)

NO-I’M NOT INTERESTED

Can I ask why? The description of the study and the few, short screening questions to determine your eligibility will only take a few minutes and are very important for this study .

I’M TOO BUSY (provide “busy” response below)

ANY OTHER RESPONSE Record response below:

______________________________________________________________________________________________________________________________________________________________________________________________________

Thank you for your time.

I’M TOO BUSY

Is there a better time I can call you, evenings and weekends are fine? (Record in comments column)

NO

Can I try back tomorrow, next week, etc?

YES-I’M INTERESTED

Great! Well first I have to ask you a few questions to determine your eligibility.

GO AHEAD.

I AM GOING TO START BY ASKING SOME QUESTIONS ABOUT YOU, THEN SOME GENERAL QUESTIONS. PLEASE REMEMBER THAT YOU CAN REFUSE TO ANSWER ANY QUESTION I ASK.

1. In what year did you first obtain your license to practice pharmacy?

______

7777 Not Applicable

8888 Don’t Know

9999 Refused to answer

2. Are you the:

[READ]

0 Owner

1. Managing or supervising pharmacist

2. Staff pharmacist

3. Manager

4. Other (please specify_________________________________________)

8888 Don’t Know

9999 Refused to answer

3. On average about how many new customers do you sell non-prescription syringes to in one month?

[PROBE: If participant isn’t sure: Do you have ANY, over five, over 10? Can you ask someone else in your pharmacy who might know?]

____ ____ ____ ____ customers

8888 Don’t know

9999 Refuse

4. During the course of one month, how many of those new customers become regulars—that is, they come back repeatedly to purchase syringes?

____ ____ ____ ____ customers

8888 Don’t know

9999 Refuse

5. Of the syringe customers over the course of a month, with how many different customers do you have a conversation?

____ ____ ____ ____ customers

8888 Don’t know

9999 Refuse

6. What did you talk about? [DO NOT PROMPT] (check all that apply)

0 Drug treatment

1 What the syringe was going to be used for

2 Safe injection practices

3 Disposal of syringes

4 Other [Specify ____________________________________________]

8888 Don’t know

9999 Refused

7. What do you currently require of a customer when selling non-prescription syringes? [Prompt: such as ID, signing a logbook or anything else] (check all that apply)

0	My pharmacy requires no additional procedures for selling needles/syringes
1	Diabetic identification
2	Knowledge of diabetes, insulin or other injectable medication
3	Identification if they look underage
4	Any other identification
5	Name and/or address or signature
6	Reason for purchasing
7	Other (specify)________________________________________________
8888	Don’t Know
9999	Refuse to answer

9. What is your gender?

0 Male

1. Female

9999 Refused to answer

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

01 Yes

02 No

b. What race do you consider yourself (check all that apply)?

1. Black or African-American [A7b]

2. White [A8]

3. Asian [A8]

4. Native Hawaiian or Other Pacific Islander [A8]

5. American Indian or Alaskan Native [A8]

- - Refused [A8]

++ Don’t know [A8]

PLEASE GIVE ME A MOMENT TO DETERMINE YOUR ELIGIBILITY

If answered:

Question 3: New ESAP customers = ≥ 3

Question 4: Regulars/month = ≥ 2

Question 7. Does not have additional requirements to sell syringes.

Then ELIGIBLE

IF NOT ELIGIBLE: Sorry, you are not eligible for the study. Thank you for your interest and your time.

IF ELIGIBLE: Your pharmacy is eligible to take part in the study. Do you have five minutes so I can briefly tell you about the research project and your role in it?

IF YES: Great! You're eligible to take part in another survey. It should take about ten minutes and it includes questions about your ESAP customers and the services provided in your pharmacy. You also may be eligible to take part in a larger study which you will compensated for. Would you like to take the survey now or at a later time?

IF PHARMACIST DOESN’T HAVE TIME IMMEDIATELY: schedule a convenient time to complete the baseline and end the call.

IF PHARMACIST REFUSES: Discuss with them the benefits of the study and offer to speak with them at a more convenient time. If pharmacist still does not want to participate, thank them for the time and end the call.

IF PHARMACIST HAS TIME TO COMPLETE THE BASELINE: End the screener ACASI file, read and obtain pharmacists’ verbal consent and begin the baseline survey.

Date _____________________ Time ____________________

THANK YOU VERY MUCH FOR YOUR TIME. HAVE A GREAT DAY!