Form Approved
OMB No. 0920-0840
Expiration Date 01/31/2013
Web-based HIV Behavioral Surveillance System: Screening Questionnaire for Focus Groups
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.
Attachment 1a: Screening Questionnaire for Focus Groups
In
Person Focus Group Interviewer says: Hi,
my name is [name] and I am working with Emory University on an HIV
research study to help improve health services for men in the
United States. We’re trying to find guys in our community who can share their opinions about a new behavioral research study we are designing for men. May I ask you a few questions to see if you would be eligible to participate?
If ‘No’: Thank you for your time.
If ‘Yes’, proceed to Question 1 |
Online Focus Group
Emory
University is working on an HIV research study to help improve
health services for men in the United States. We’re trying to find guys in our community who can share their opinions about a new behavioral research study we are designing for men. May we ask you a few questions to see if you would be eligible to participate?
If ‘No’: Thank you for your time.
If ‘Yes’, proceed to Question 1
|
1. How old are you? _______ years
If Respondent is <18
years old, skip to End1
2. Do you consider yourself to be Hispanic or Latino/a?
No………………….……………………………0
Yes………………………………………………1
Refused to answer………………………7
Don't know……………..……………………...9
3. What best describes your Hispanic or Latino ancestry?
Mexican…………….…..……………………… 1
Puerto Rican………..…………………………... 2
Cuban…………...…………………..………….. 3
Dominican……...…………………..………….. 4
Some other ancestry (Specify_____)…………... 5
Refused to answer………....…………………… 7
Don't know………………………..……………. 9
4. Which racial group or groups do you consider yourself to be in? You may choose more than one option.
American Indian or Alaska Native…………………..1
Asian ..……………………..………………...............................2
Black or African American ……………..…………..3
Native Hawaiian or Other Pacific Islander……………….4
White ……………..………………………………………………………5
Refused to answer………………………………………………….7
Does not apply ……………………………………………………..8
Don’t know……………………………………………………………..9
5. What U.S. state or U.S. Territory do you live in?
6. What are the first three digits of your zip code?
7. What was your sex at birth? [CHECK only ONE]
Male…...………………………………………. 1
Female…....…....…………………………… 2
Intersex/ambiguous………....………… 3
Refused to answer………....………….. 7
Don't know……………..……………………. 9
8. Do you consider yourself to be male, female, or transgender? [CHECK only ONE]
Male…………………………………………….. 1
Female …………………………………………. 2
Transgender ………………………………… 3
Refused to answer……………………….. 7
Don't know……………..…………………….. 9
This next question is about having sex with other men. Oral sex
means he put his mouth on your penis or you put your mouth on his
penis. Anal sex means you put your penis in his anus (butt) or he
put his penis in your anus (butt).
ES9. Have you ever had oral or anal sex with a man?
No………………….………….……………….. 0
Yes………………………………..…………..... 1
Refused to answer……………………… 7
CONSENTA. Do you agree to take part in the focus group discussion?
No………………….……………….………..... 0
Yes….……………………………….……......... 1
If CONSENTA = 0, skip to decline
If
(age < 18) OR female OR has never had oral or anal sex with a man
OR does not agree to take part in the focus groups then say:
I’m sorry, based on your answers you aren’t eligible to participate. Thank you for your time!
In
Person Focus Group If eligible then say:
You are eligible to participate. If you are interested, we would schedule a time for you to come to Emory to participate in a focus group. The research would last no more than an hour and a half, and you would receive $40 as a token of appreciation. May I get your first name and cell phone number or email address so we can arrange a time for you to participate?
If yes: Name (first name only): _________________________ Cell phone number: _____________ OR email address: ______________
|
Online
Focus Group If eligible then say:
You are eligible to participate. If you are interested, we would schedule a time for you to come to Emory to participate in a focus group. The research would last no more than 2 hours, and you would receive $25 as a token of appreciation. May I get your first name and cell phone number or email address so we can arrange a time for you to participate?
If yes: Name (first name only): _________________________ Cell phone number: _____________ OR email address: ______________
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Eli R. |
| File Modified | 0000-00-00 |
| File Created | 2021-02-03 |