Evaluation of Rapid HIV Self-Testing: Qualitative and User Proficiency Assessments

Form Approved

OMB No. 0920-0840

Expiration Date: 00/00/0000

Evaluation of Rapid HIV Self-Testing: Qualitative and User Proficiency Assessments

Attachment 1a

Eligibility Screener

Public reporting burden of this collection of information is estimated to average 5 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)

Eligibility Screener

Thank you for your interest in our study. First, we have a few questions to determine if you’re eligible. Please take 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. Some questions are about sensitive topics; you can choose not to answer any question that you are not comfortable with.
3. If you have any questions or comments, you may contact the Principal Investigator, Dr. Patrick Sullivan of Emory University, at (404) 727-2038.

____________________________________________________

AUTO1. Date of Interview: __ __/ __ __ / __ __ __ __

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

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

QS1. How old are you? _ _ _

If ES1 <18 skip to End1

QS2. Do you consider yourself to be Hispanic or Latino?

No

Yes

I prefer not to answer

Don't know

QS3. Which racial group or groups do you consider yourself to be in? Check all that apply:

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

I prefer not to answer

Does not apply

Don’t know

Q4. What zipcode do you live in?

__ __ __ __ __

If QS4≠ one of the study cities, skip to End 1

Gender Assessment and Identity

QS5. What was your sex at birth?

[Check only one]

Male

Female

Intersex/Ambiguous

I prefer not to answer

Don't know

QS6. Do you consider yourself to be male, female, or transgender?

[Check only one]

Male

Female

Transgender

I prefer not to answer

Don't know

If QS5 and QS6 =Male, go to QS7

If QS5 and QS6 ≠ MALE, skip to End 1

Sex risk assessment

The next question is about having sex with other men. For this question, "anal sex" means you put your penis in his anus (butt) or he put his penis in your anus (butt).

QS7. Have you had anal sex with a man in the past 12 months?

No

Yes

I prefer not to answer

Don't know

If QS7 ≠Yes, skip to End1

HIV Testing

QS-8. Have you ever been tested for HIV? An HIV test checks whether someone has the virus that causes AIDS.

No

Yes

I prefer not to answer

If QS8= Yes, go to QS9

If QS8= No, go to QS10

If QS8= I prefer not to answer, skip to End 1

QS9. Have you ever tested positive for HIV?

No

Yes

I don't know

I prefer not to answer

If QS9 = I prefer not to answer, skip to End 1

If QS9 = “Yes”, then classify participant into “Positive Arm”

If QS9 = “No” or “I don’t know”, then classify participant into “Negative Arm” and proceed to randomization process

Contact Information

We will communicate with you via email, phone or text message to schedule a time for you to participate in a research session. We will also contact you to remind you about the date, time and place of the research session. This information will not be shared or used for any other research purposes.

*required

QS10a. Email address*: ____________________

QS10b. Telephone number to receive calls*: ___________________

QS10c. Telephone number to receive text messages: ___________________

If QS10 is not answered go to End 1

QS11. We will not ask your name as part of the participation in the study. Please provide us with an alias or name of your choice that we can use throughout the study to communicate with you.

Nickname or name of choice _______________

QS12. Your login will be the email address you provided. Please create a password that you will use to access the study website.

End 1. If the participant does not qualify:

Thank you for your interest in this study. Unfortunately, you are not eligible to participate any further. Thank you for your time.

End survey.

End 2. If the participant qualifies:

Congratulations! You qualify to participate in this health study.

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

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