Screener - Testing in Rural Black Men

“HIV Testing Factors Among Rural Black Men (HiTFARM)”

Attachment 1a. Screening Form and Contact Form

Form Approved

OMB No. 0920-0840

Expiration Date 01/31/2013

“HIV Testing Factors Among Rural Black Men (HiTFARM)”

Screening Form and Contact Form

Public reporting burden of this collection of information is estimated to average 5 minutes per response. 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)

1. Age ______ (years) 2. Gender: Male Female

3. What county do you live in? (Select only one)

Columbia County

Hamilton County

Alachua County

3a. If Alachua County, which city or town? (Select only one)

Gainesville

High Springs

Alachua

LaCrosse

Hawthorne

Newberry

Jonesville

Micanopy

Orange Heights

Melrose

Fairbanks

Waldo

4. How would you describe your ethnicity?

Hispanic or Latino

Not Hispanic or Latino

4. How do you describe your race? (Mark all that apply)

American Indian or Alaskan Native

Asian

Black or African/American

Native Hawaiian or other Pacific Islander

White

5. How do you usually identify yourself to male or female friends? (Select only one)

As a straight guy who sleeps with women only

As a straight guy who sleeps with women & other guys

As a straight guy who sleeps with other guys only

I do not label myself, but sleep with other guys

As bisexual

As gay

Transgender

I do not discuss this with them

When were you last tested for HIV?

Never

Within the past three months ________________ (please give date)

Longer than three months age _______________ (please give date)

C oalition

for H ealth

and A dvocacy

of R ural

Minorities

CONTACT INFORMATION

Name: (Last)________________________ (First)________________________

Date of Birth: (Month/Day/Year) _______________________________________

Address: (Street) ____________________________________________________

(City)_______________________(State)_________(Zip Code)________

Home Phone: ­­­­­­­­­­­­­­­­(____)__________________________________________________

Is it okay if we leave a message for you at this number? ______________

Cell Phone: (____)__________________________________________________

Is it okay if we leave a message for you at this number?________________

Message Phone: (_____)_______________________________________________

Hang out locations: ___________________________________________________

Contact #1: Date of contact__________________________

Outcome:____________________________________________________________

Contact #2: Date of contact:____________________________________________

Outcome:____________________________________________________________

____________________________________________________________________

Contact #3: Date of contact:____________________________________________

Outcome:____________________________________________________________

_____________________________________________________