Assessment of QDS System-screener

Assessment of a QDS Data Collection System in HIV Prevention

Program Evaluation

#0920-0840

Expiration date: 31 January 2013

ATTACHMENT 3

Screener Form

Assessment of a QDS Data Collection System in HIV Prevention Program Evaluation

Screener Form

Date approved: 01/21/2010

OMB Control Number: 0920-0840

Expiration date: 31 January 2013

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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0840)

Screener Form

1. Recruitment site ______________________

2. Staff ID ________________________

3. Data collection date: __ __ / __ __ /__ __ __ __ (MM/ DD/YYYY)

4. What was your sex at birth?

Male

Female (ineligible)

Decline to answer

5. How old are you? ________________ (client must be at least 16 years old to participate)

6. Have you participated in an M group in the last 12 months?

Yes (ineligible)

No

7a. Have you participated in an Mpowerment (insert local name here) discussion group in the last 12 months? (core groups, support groups)

Yes

No

7b. If yes, how many times have you participated? ____ (ineligible if greater than once)

8a. Have you attended Mpowerment (insert local name here) social events in the last 12 months?

Yes

No

8b. If yes, how many times have you attended? ____ (ineligible if greater than twice)

9a. Have you visited the project space (insert local name here) in the last 12 months?

Yes

No

9b. If yes, how many times have you visited the project space? ____ (ineligible if greater than 3 times)

10. Have you participated in any Mpowerment activities at another agency (insert local name here)?

Yes (ineligible)

No

Note: Past exposure to Mpowerment can only total to 3 or fewer events in the last 12 months. This number can be calculated be adding questions 7b, 8b, and 9b.

If individual is eligible but declined to participate, please explain the reason below:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

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