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 1d

User Proficiency Assessment Survey

Public reporting burden of this collection of information is estimated to average 10 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)

Self-Test Results

To be completed by Participant

Date: ____/____/____

Tests Conducted by Participant ID # _______________

Instructions: After performing each self-test, please check the result option. Write down any comment you have in the comment boxes.

Rapid Self- Test 1: OraQuick Advance Rapid HIV-1/2 Antibody Test

Sample Type: Oral Fluid

Result (Please check one of the answers):

____ Preliminary Positive

_____Negative

_____Invalid

Rapid Self- Test 2: SURE CHECK® HIV 1/ 2 Assay (Clearview)

Sample Type: Whole blood finger stick

Result (Please check one of the answers):

____ Preliminary Positive

_____Negative

_____Invalid

Proficiency Assessment Survey

Date: ____/____/____

Participant ID # _______________

1. What is the highest level of education you have completed?

___ Less than high school

___ Some high school

___ High school diploma or GED

___ Some college, Associate’s Degree, or Technical Degree

___ College, post graduate or professional school

2. What is your age?

______

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

___ No

___ Yes

4. 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

5. Have you ever had a job where you conduct laboratory tests or experiments?

___ Yes

___ No

6. Have you ever used “The Home Access® HIV-1 Test System”, where you collect your own blood sample and ship it to the Home Access laboratory?

___ Yes

___ No

7. Have you ever used any other kind of over-the-counter self-test before? Examples of these tests include cholesterol.

___ Yes. Which test? ___________________________

___ No

Post-test Evaluation

Self-testing

1. What type of additional training or information, if any, would you have liked to have had before performing the tests? (Check all that apply)

___ No additional training/information was needed besides the instructions provided

___ Additional video demonstration

___ Demonstration in person by laboratory worker

___ More detailed written instructions

___ Other: ________________________________________________

2. After you completed the Oraquick (oral fluid test), how confident were you that you could perform the test according to the instructions?

___ Very Confident

___ Somewhat confident

___ Not very confident

___ Not confident at all

3. After you completed the Sure Check test (finger stick test), how confident were you that you could perform the test according to the instructions?

___ Very Confident

___ Somewhat confident

___ Not very confident

___ Not confident at all

4. What questions, if any do you still have about how to perform the test?

DBS specimen collection and packaging

5. What type of additional training, if any, would you have liked to have had before the dried blood spot sample? (Check all that apply)

___ No additional training was needed besides the instructions provided

___ Additional video demonstration

___ Demonstration in person by laboratory worker

___ More detailed written instructions

___ Other: ________________________________________________

6. After you collected the blood sample on the DBS card, how confident were you that you could collect your own blood sample according to the instructions?

___ Very Confident

___ Somewhat confident

___ Not very confident

___ Not confident at all

7. After you finished packaging the DBS card, how confident were you that you could package the DBS card according to directions?

___ Very Confident

___ Somewhat confident

___ Not very confident

___ Not confident at all

8. What questions, if any do you still have about how to collect and package a DBS sample?