Screen shots

Public reporting burden of this collection of information is estimated
to average 15 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)

Select Next Question

Select Next Question

1

Enter Participant ID and select Next Question

Select appropriate interviewer ID

2

Select appropriate device ID

Select Next Question

3

Select Next Question

Enter birthday and select Next Question

4

Select appropriate sex

Select appropriate ethnicity

5

Select appropriate race and then select Next Question

________________________________________________________________________

Should survey participant answer NO
[See Page 8 should the participant say YES to being prior HIV test]

6

Enter in health care facility and select Next Question

Select Next Question

7

Save the file and set up for next interview

________________________________________________________________________
Cont’d Pg 6 SHOULD THE PARTICIPANT SAY YES TO PRIOR HIV TESTS

Should the participant say YES
[Should the participant say NO to positive test results see page 10]

8

Select Next Question

Enter year and month and select Next Question on answer applicable

9

Enter clinic and then select Next Question or answer that is applicable
Next Question to follow should be “Have you ever had a negative HIV test result”

Cont’d Pg 8 PARTICIPANT RESPONDED “NO” TO POSITIVE HIV TEST

Select Yes OR No if prior testing was negative

10

Select Next Question

Enter year and month and select Next Question or answer that applies

11

Enter facility and select Next Question or Select answer that applies

Enter facility and select Next Question or answer that applies

12

Select Next Question

Save file and set up for next interview

13