Web-based Survey - Web Survey Screener

Form Approved

OMB No. 0920-0840

Expiration Date 01/31/2013

Web-based HIV Behavioral Surveillance System

Eligibility Screener

Public reporting burden of this collection of information is estimated to average 1 minute 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, Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0840). Do not send the completed form to this address.

Web-based HIV Behavioral Surveillance System: Eligibility Screener

_____________________________________________________

Thank you for your interest in our survey. Please note of the following information:

1. Your answers are anonymous: we don’t have any information about who you are beyond the questions you answer.

2. This survey includes some personal questions. You can choose to not answer any questions that make you feel uncomfortable.

AUTO1. Date of Interview: __ __/ __ __ / __ __ __ __ {IDATE }

^{(M M / D D / Y Y Y Y )}

AUTO2. Time Began Eligibility Screener __ __:__ __ :__ __ [24 Hour time HH:MM:SS] {START_ELIG}

ES1. How old are you? _ _ _ {AGE}

IF ES1< 18, skip to End1 Don’t know = 999; Skip to End 1

ES2. During 20xx, did you already complete at least part of the <name of survey>? {E_PART}

No………………….……………….………....…0

Yes….……………………………….……......... 1

I prefer not to answer.……………..…………….7

Don't know.……………..……………….......... 9

ES3. Do you consider yourself to be Hispanic or Latino? {HISPANIC}

No………………….……………………………0 Yes……………………………………………...1

I prefer not to answer.……………..…………….7

Don't know……………..…………………….... 9

ES4. Which racial group or groups do you consider yourself to be in? Check all that apply:

American Indian or Alaska Native…………… 1 {RACEA}

Asian ..……………………..………………....... 2 {RACEB}

Black or African American ……………..…….. 3 {RACEC}

Native Hawaiian or Other Pacific Islander……..4 {RACED}

White ……………..……………………………. 5 {RACEE}

I prefer not to answer.……………..…………….7

Does not apply……………..…………………...8

Don’t know……………………………………..9

ES5. What U.S. State or U.S. Territory do you live in? {STA_TERR}

[DROP DOWN MENU LISTS ELIGIBLE STATES AND TERRITORIES and “I don’t live in the United States” for non-U.S. States or Territories]

[Don’t Know=99]

ES6 Do you consider yourself to be male, female, or transgender? {GENDER}

Male…………………………………………….. 1

Female …………………………………………. 2

Transgender ……………………………………. 3

I prefer not to answer.……………..…………….7

Don't know……………..…………………….....  9

If ES6 ≠ 1, skip to End 1.

ES7a. Have you ever had vaginal sex (penis in the vagina) or anal sex (penis in the butt) with a woman? {E_EVRMSW}

No………………….……………………………  0

Yes……………………………………………...  1

I prefer not to answer.……………..…………….7

Don't know……………..…………………….....  9

ES7b. Have you ever had oral sex (mouth on the penis) or anal sex (penis in the butt) with a man? {E_EVRMSM}

No………………….………….………………..  0 Yes………………………………..………….....  1

I prefer not to answer.……………..…………….7

Don't know……………..………….………......... 9

If ES7b = 7 or 9, skip to End 1

If ES2=0 and ES6=1 and ES7b=1 and ES5≠(’Other’ or 99), then go to End 2.

Else, go to End 1.

End 1. If the participant is NOT ELIGIBLE:

Thank you for completing the survey. Unfortunately, you were not selected to participate any further. Thank you for your time.

End Interview.

End 2. If the participant is ELIGIBLE:

{Consent screen displays}

CONSENT. If you agree to take this survey, please click here. {CONSENT}

No………………….……………….………..... 0

Yes….……………………………….……........ 1

ES8. What [county/municipality] do you live in? {COU_MUN}

[DROP DOWN MENU LISTS ELIGIBLE COUNTIES]

[Refuse to answer = 77; Don’t Know=99]

If ES8= 99, then End1. If ES8≠99, then proceed to DM-1.

AUTO3. Time Ended Eligibility Screener: __ __:__ __ : __ __ [24 Hour time HH:MM:SS] {END}

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