Form Approved
OMB No. 0920-0840
Expiration: 01/31/2013
Screener Form
Public reporting burden of this collection of information is estimated to average 3 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).
Monitoring and Evaluation of MPowerment (MEM) Eligibility Screener- Community Level Assessment (CLA)
This form should be completed (by MEM staff) for each individual screened to complete the CLA survey.
1. Recruitment site ______________________ Screener ID: ________ |
2. Staff ID ________________________ CLA1 and CLA2 _______________ |
3. Today’s date: __ __ / __ __ /__ __ __ __ (MM/ DD/YYYY) |
4. What is your current gender? Male Female (ineligible) Transgender |
5. Do you live in Atlanta/Chicago/San Diego area?
Yes
No (ineligible) |
6. How many months have you lived in [Designated area] _____ (Ineligible if have only lived in area for 3 months)
|
7. How old are you? ________________ (participant must be at least 16 years old to participate)
|
8. Do you consider yourself to be . . . (Choose one) Gay, Homosexual, Same Gender Loving, etc (Skip to Q10) Bisexual (Skip to Q10) Heterosexual or “Straight” Questioning (Skip to Q10) Decline to answer Other (Specify if orientation other than the choices above): ___________________________
|
9. Have you had sex with a man in the last year? Yes No (ineligible) |
10. Have you participated in [INSERT NAME OF YOUR LOCAL MEM ACTIVITY HERE]? San Diego? In the past 12 months have you participated in any surveys in [Local MEM group]? Yes (ineligible) No |
11. Are you… (Choose one) (optional) Hispanic or Latino Non-Hispanic African American Non-Hispanic White Other ___________________________ |
12. Are you interested in participating in [INSERT NAME OF YOUR LOCAL CLA ACTIVITY HERE]? Yes No |
13. Do you consent to participate in [INSERT NAME OF YOUR LOCAL CLA ACTIVITY HERE]? Yes No |
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | hkh3 |
| File Modified | 0000-00-00 |
| File Created | 2021-02-03 |