Screener

Request for Sub-collection Under the

Approved Generic ICR: Formative Research and Tool Development

OMB No. 0920-0840,

Expiration 31 January 2013

Minority HIV/AIDS Research Initiative (MARI) Project:

Sexual risk-taking among young black men who have sex with men: exploring the social and situational contexts of HIV risk, prevention, and treatment (BROTHERS CONNECT STUDY)

Attachment 1a. Screening and Contact Info Forms

Form Approved

OMB No. 0920-0840

Expiration Date 01/31/2013

“Sexual risk-taking among young black men who have sex with men: exploring the social and situational contexts of HIV risk, prevention, and treatment (BROTHERS CONNECT STUDY)”

Screening and Contact Info Forms

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: OMB-PRA (0920-0840)

BCS SCREENING FORM

Name: _______________ Phone Number: _______________ Date/Time: _______________

1. What is your date of birth? _____/_____/_____

Month Day Year

2. What is your gender? Male Female Transgender

3. Do you have a private email address that you check regularly?

Yes No

4. Do you have access to a private computer that is connected to the Internet that you use regularly?

Yes No

5. Have you engaged in sexual activity (sexual intercourse, oral sex) with another man in the past two months?

Yes No

6. How would you describe your race/ethnicity?

____________________________________

7. How did you find out about the Brothers Connect Study?

____________________________________

For screener to answer:

A. Based on the phone conversation, was the potential participant English proficient?

Yes No

B. Person eligible? (over 18 yrs old; for items 2 & 5 BOLD response option selected; for item 6, noted Black, African-American, Black Latino, Caribbean/West Indian, mixed-race Black/African-American )

Yes No

C. If yes, orientation scheduled?

Yes No

Date:_______ Time:_______ Staff:_______

BCS PARTICIPANT CONTACT INFO FORM

_________________

DATE

_________________________ _____________________ ­­________________

Month / Day / Year

FIRST NAME LAST NAME DATE OF BIRTH

____________ @ ________________

EMAIL ADDRESS Please provide an email address that you check frequently (every day)

_____ - _______________ Home Cell Work Can call? Leave message?

PHONE NUMBER 1 Please circle one Please circle if OK

_____ - _______________ Home Cell Work Can call? Leave message?

PHONE NUMBER 2 Please circle one Please circle if OK

____________________ ______________ _________ _______ ________

House Number & Street Apt/Unit City State Zip Code

HOME ADDRESS

HOW DID YOU FIND OUT ABOUT BROTHERS CONNECT STUDY?

__________________________________________________________

MAY WE CONTACT YOU IN THE FUTURE FOR STUDIES THAT YOU MAY BE ELIGIBLE TO PARTICIPATE IN?

Yes No

DO YOU KNOW OTHER YOUNG BLACK MEN (18-30 YRS. OLD) WHO WOULD BE INTERESTED IN PARTICIPATING IN THIS STUDY?

Yes No

If yes, please see a member of the research team to find out how we can contact the person, or have them contact us.

FOR BROTHERS CONNECT STAFF TO COMPLETE:

ID number assigned: ___________ Token: ____________ Staff Initials: ________

Cross-sectional survey participant YES NO

Sex diary participant YES NO

Interview participant YES NO

BCS STAFF TO COMPLETE FOR SEX DIARY PARTICIPANTS:

WEEK 1: REMINDER 1 SENT? YES NO Date: ________ Staff Initials: ________

REMINDER 2 SENT? YES NO Date: ________ Staff Initials: ________

REMINDER 3 SENT? YES NO Date: ________ Staff Initials: ________

ASSMT COMPLETED: YES NO Date: ________ Staff Initials: ________

WEEK 2: REMINDER 1 SENT? YES NO Date: ________ Staff Initials: ________

REMINDER 2 SENT? YES NO Date: ________ Staff Initials: ________

REMINDER 3 SENT? YES NO Date: ________ Staff Initials: ________

ASSMT COMPLETED: YES NO Date: ________ Staff Initials: ________

WEEK 3: REMINDER 1 SENT? YES NO Date: ________ Staff Initials: ________

REMINDER 2 SENT? YES NO Date: ________ Staff Initials: ________

REMINDER 3 SENT? YES NO Date: ________ Staff Initials: ________

ASSMT COMPLETED: YES NO Date: ________ Staff Initials: ________

WEEK 4: REMINDER 1 SENT? YES NO Date: ________ Staff Initials: ________

REMINDER 2 SENT? YES NO Date: ________ Staff Initials: ________

REMINDER 3 SENT? YES NO Date: ________ Staff Initials: ________

ASSMT COMPLETED: YES NO Date: ________ Staff Initials: ________

WEEK 5: REMINDER 1 SENT? YES NO Date: ________ Staff Initials: ________

REMINDER 2 SENT? YES NO Date: ________ Staff Initials: ________

REMINDER 3 SENT? YES NO Date: ________ Staff Initials: ________

ASSMT COMPLETED: YES NO Date: ________ Staff Initials: ________

WEEK 6: REMINDER 1 SENT? YES NO Date: ________ Staff Initials: ________

REMINDER 2 SENT? YES NO Date: ________ Staff Initials: ________

REMINDER 3 SENT? YES NO Date: ________ Staff Initials: ________

ASSMT COMPLETED: YES NO Date: ________ Staff Initials: ________

WEEK 7: REMINDER 1 SENT? YES NO Date: ________ Staff Initials: ________

REMINDER 2 SENT? YES NO Date: ________ Staff Initials: ________

REMINDER 3 SENT? YES NO Date: ________ Staff Initials: ________

ASSMT COMPLETED: YES NO Date: ________ Staff Initials: ________

WEEK 8: REMINDER 1 SENT? YES NO Date: ________ Staff Initials: ________

REMINDER 2 SENT? YES NO Date: ________ Staff Initials: ________

REMINDER 3 SENT? YES NO Date: ________ Staff Initials: ________

ASSMT COMPLETED: YES NO Date: ________ Staff Initials: ________

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