Recruitment - 1a Screener

Form Approved

OMB No. 0920-0840

Expiration Date 01/31/2013

Web-based HIV Behavioral Survey Among MSM: 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.

The information in this report to the Centers for Disease Control and Prevention (CDC) is authorized by law (Sections 304 and 306 of the Public Health Service Act, 42 USC 242b and 242k). Response to this survey is voluntary. Your cooperation is necessary for the understanding and control of HIV/AIDS. Information in CDC’s HIV/AIDS surveillance system that would permit identification of any individual on whom a record is maintained, is collected with a guarantee that it will be held in confidence, will be used only for the purposes stated in the assurance on file at CDC, and will not otherwise be disclosed or released without the consent of the individual in accordance with Section 308(d) of the Public Health Service Act (42 USC 242m(d)).

Attachment 1a: Screening Questionnaire for Focus Groups

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!

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: ______________