Attachment 3a – MSM targeted screener
The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).
Public reporting burden for this collection of information is included in the interview minutes, 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, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).
OMB #0920-0222; Expiration Date: 03/31/2013
Sample screening script for MSM targeted respondent contact by QDRL Laboratory Manager/QDRL Staff for
National HIV Behavioral Surveillance (NHBS) system, and questions regarding sexual identity for the
National Health Interview Survey (NHIS)
recruited through staff of LGBT community centers, flyer, and word-of-mouth
Recruited through flyer or word-of-mouth and respondent has left a phone message on the QDRL answering machine:
Dial respondent’s telephone number [hereafter referred to as R] as indicated on audiotape recording.
Note: Speak only to R. If the number is answered by an answering machine, call back at another time.
Laboratory Manager: Good morning/afternoon, may I speak to (name)?
If R is not available or not at home, say, “Thank you” and try again at another time.
If the person who answered the phone (NOT R) asks, “Who is calling?” or “What’s this about?” say, “I am returning their call to me. I’ll try to reach them at another time.
If R has been successfully contacted, continue...
...Hello, my name is [Laboratory Manager’s name]. I am calling from the National Center for Health Statistics. You may remember that you responded to a flyer we placed in [LGBT Community Center Name] looking for Men aged 18 years and over who have sex with men to test survey questions on behaviors that might put someone ask risk for contracting HIV (the virus that causes AIDS).
Wait for acknowledgment, such as, “Oh, yes, I remember.”
...In order to determine if you are eligible for our study, I’ll need a few minutes of your time to ask some background questions. Answering these questions is completely voluntary. We are required by law to use your information for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you without your consent. Is this a good time to ask the questions or should I call back later?
If not a good time to talk, schedule a time to call back.
If good time to talk, continue and go to screener question 1.
Recruited in person at the LGBT community center through staff and flyer:
...Hello, my name is [QDRL Laboratory Manager’s or QDRL Staff name]. The National Center for Health Statistics is here today testing survey questions on behaviors that might put someone ask risk for contracting HIV (the virus that causes AIDS). Topics include sexual identity, sexual behavior, HIV testing, and antiretroviral medications.
...In order to determine if you are eligible for our study, I’ll need a few minutes of your time to ask some background questions. Answering these questions is completely voluntary. We are required by law to use your information for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you without your consent.
Wait for acknowledgment, such as, “Okay.” Continue and go to screener question 1.
1. How old are you? [If under age 18, go to exit script 1]
________________
2. Were you assigned a male physical sex at birth?
Yes
No [Go to exit script 2]
3. Do you identify, live, or present as a man?
Yes
No [Go to exit script 3]
4. Have you engaged in oral or anal sex with a male sex partner at least once in your lifetime?
Yes
No [Go to exit script 4]
5. Have you ever tested positive for HIV?
Yes
No
[If quota has been met, go to exit script 5. Otherwise continue].
6. How many years of education do you have?
9 or less 10 11 12 13 14 15 16 17 18 19
7. Are you Spanish, Hispanic or Latino?
Yes
No
8. What race or races do you consider yourself to be? You may indicate more than one race.
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
9. Would you say that your total household income last year was more or less than $50,000?
If MORE, ask: Would you say that your total household income last year was more or less than $80,000?
If LESS, ask: Would you say that your total household income last year was more or less than $25,000?
Entry Script:
...Based on your answers to the questions so far, we would like you to take part in our study. For this study we’d like you to come here to the National Center for Health Statistics in Hyattsville, MD. An interviewer will ask you questions on behaviors that may put someone at risk for contracting HIV, the virus that causes AIDS. Topics include sexual identity, sexual behavior, HIV testing, and antiretroviral medications. These questions will be used on large-scale surveys to help us understand more about patterns of HIV transmission in the United States. Then the interviewer will ask you to explain what you were thinking as you answered the questions. The interviewer will also ask you about your opinions of the questions. Your answers will help us find out if the survey questions will be easy for other people to answer. Everything you say will be kept private. With your permission, we would like to audio record your interview. The audio tape is a record of what we asked and what you said about the questions. Do you give permission to have your interview audio taped? Yes/No. [If no, go to exit script 6. Audio taping is essential for this project].
Do you have any questions at this point? Pause to answer questions. If (not/you have no other questions), then let’s get you on the schedule, ok? We will be interviewing (Day, Month/Date) through (Day, Month/Date) from 8 a.m. to 6 p.m. Looking at your schedule, when would you be available to participate? Schedule. [If date/times not available go to exit script 7.]
A reminder call will be made to you a few days in advance. Should you have any questions or need to change your appointment, please feel free to contact me [name] at [phone number]. Thank you for responding to our ad, and I look forward to seeing you here at (DATE/TIME) Get respondent to cite date & time if possible.
---------------------------------------------------------
Exit script 1: I’m sorry, you have to be over the age of 18 to take part in this study and therefore we won’t be able to use you at this time. However, I would like to put your name and telephone number you gave me into our database so that I can contact you about other studies coming up in the future. Is that OK? If yes, record name & telephone number. If no: OK, thank you for your time. Your name and telephone number will not be added to our database.
Exit script 2: I’m sorry, you have to be assigned a male physical sex at birth to take part in this study and therefore we won’t be able to use you at this time. However, I would like to put your name and telephone number you gave me into our database so that I can contact you about other studies coming up in the future. Is that OK? If yes, record name & telephone number. If no: OK, thank you for your time. Your name and telephone number will not be added to our database.
Exit script 3: I’m sorry, you have to identify, live, or present as a man to take part in this study and therefore we won’t be able to use you at this time. However, I would like to put your name and telephone number you gave me into our database so that I can contact you about other studies coming up in the future. Is that OK? If yes, record name & telephone number. If no: OK, thank you for your time. Your name and telephone number will not be added to our database.
Exit script 4: I’m sorry, you have to have engaged in oral or anal sex with a male sex partner at least once in your lifetime to take part in this study and therefore we won’t be able to use you at this time. However, I would like to put your name and telephone number you gave me into our database so that I can contact you about other studies coming up in the future. Is that OK? If yes, record name & telephone number. If no: OK, thank you for your time. Your name and telephone number will not be added to our database.
Exit script 5: Based upon your answers, it seems that we may already have a number of volunteers with very similar answers to yours. At this point we need to talk with people with some different characteristics. However, if we have cancellations or other slots open up, I may wish to call you back. Would it be okay if I kept your name, telephone number, and the information you provided in response to the eligibility questions until the end of this study? If yes, make notation. If no, Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, add to database. If no: OK, thank you for your time. Your name and any information you gave me will not be added to our database.
Exit script 6: I’m sorry, willingness to be audio taped is required in order to take part in this study and therefore we won’t be able to use you at this time. Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, add to database. If no: OK, thank you for your time. Your name and any information you gave me will not be added to our database.
Exit scrip t 7: I see...ok, we were hoping to complete this particular study between (Month/Date) and (Month/Date), so it looks like we won’t be able to schedule you at this time. Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, add to database. If no: OK, thank you for your time. Your name and any information you gave me will not be added to our database.
Attachment 3b – IDU targeted screener
The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).
Public reporting burden for this collection of information is included in the interview minutes, 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, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).
OMB #0920-0222; Expiration Date: 03/31/2013
Sample screening script for IDU targeted respondent contact by QDRL Laboratory Manager/QDRL Staff for
National HIV Behavioral Surveillance (NHBS) system, and questions regarding sexual identity for the
National Health Interview Survey (NHIS)
recruited through staff of needle exchange centers, flyer, and word-of-mouth
Recruited through flyer or word-of-mouth and respondent has left a phone message on the QDRL answering machine:
Dial respondent’s telephone number [hereafter referred to as R] as indicated on audiotape recording.
Note: Speak only to R. If the number is answered by an answering machine, call back at another time.
Laboratory Manager: Good morning/afternoon, may I speak to (name)?
If R is not available or not at home, say, “Thank you” and try again at another time.
If the person who answered the phone (NOT R) asks, “Who is calling?” or “What’s this about?” say, “I am returning their call to me. I’ll try to reach them at another time.
If R has been successfully contacted, continue...
...Hello, my name is [Laboratory Manager’s name]. I am calling from the National Center for Health Statistics. You may remember that you responded to a flyer we placed in [community needle exchange center] looking for adults aged 18 year and over to test survey questions on behaviors that might put someone ask risk for contracting HIV (the virus that causes AIDS).
Wait for acknowledgment, such as, “Oh, yes, I remember.”
...In order to determine if you are eligible for our study, I’ll need a few minutes of your time to ask some background questions. Answering these questions is completely voluntary. We are required by law to use your information for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you without your consent. Is this a good time to ask the questions or should I call back later?
If not a good time to talk, schedule a time to call back.
If good time to talk, continue and go to screener question 1.
Recruited in person at the needle exchange center through staff and flyer:
...Hello, my name is [QDRL Laboratory Manager’s or QDRL Staff name]. The National Center for Health Statistics is here today testing survey questions on behaviors that might put someone at risk for contracting HIV (the virus that causes AIDS). Topics include sexual identity, sexual behavior, HIV testing, and antiretroviral medications.
...In order to determine if you are eligible for our study, I’ll need a few minutes of your time to ask some background questions. Answering these questions is completely voluntary. We are required by law to use your information for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you without your consent.
Wait for acknowledgment, such as, “Okay.” Continue and go to screener question 1.
1. How old are you? [If under age 18, go to exit script 1]
________________
2. What physical sex were you assigned at birth, male or female?
Male
Female
3. Do you identify, live, or present as a [man/woman]?
Yes
No [Go to exit script 2]
4. Have you injected drugs in the past 12 months?
Yes
No [Go to exit script 3]
5. Have you ever tested positive for HIV?
Yes
No
[If quota has been met, go to exit script 4. Otherwise continue].
6. How many years of education do you have?
9 or less 10 11 12 13 14 15 16 17 18 19
7. Are you Spanish, Hispanic or Latino?
Yes
No
8. What race or races do you consider yourself to be? You may indicate more than one race.
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
9. Would you say that your total household income last year was more or less than $50,000?
If MORE, ask: Would you say that your total household income last year was more or less than $80,000?
If LESS, ask: Would you say that your total household income last year was more or less than $25,000?
Entry Script:
...Based on your answers to the questions so far, we would like you to take part in our study. For this study we’d like you to come here to the National Center for Health Statistics in Hyattsville, MD. An interviewer will ask you questions on behaviors that may put someone at risk for contracting HIV, the virus that causes AIDS. Topics include injections drug use, sexual identity, sexual behavior, HIV testing, and antiretroviral medications. These questions will be used on large-scale surveys to help us understand more about patterns of HIV transmission in the United States. Then the interviewer will ask you to explain what you were thinking as you answered the questions. The interviewer will also ask you about your opinions of the questions. Your answers will help us find out if the survey questions will be easy for other people to answer. Everything you say will be kept private. With your permission, we would like to audio record your interview. The audio tape is a record of what we asked and what you said about the questions. Do you give permission to have your interview audio taped? Yes/No. [If no, go to exit script 5. Audio taping is essential for this project].
Do you have any questions at this point? Pause to answer questions. If (not/you have no other questions), then let’s get you on the schedule, ok? We will be interviewing (Day, Month/Date) through (Day, Month/Date) from 8 a.m. to 6 p.m. Looking at your schedule, when would you be available to participate? Schedule. [If date/times not available go to exit script 6.]
A reminder call will be made to you a few days in advance. Should you have any questions or need to change your appointment, please feel free to contact me [name] at [phone number]. Thank you for responding to our ad, and I look forward to seeing you here at (DATE/TIME) Get respondent to cite date & time if possible.
---------------------------------------------------------
Exit script 1: I’m sorry, you have to be over the age of 18 to take part in this study and therefore we won’t be able to use you at this time. However, I would like to put your name and telephone number you gave me into our database so that I can contact you about other studies coming up in the future. Is that OK? If yes, record name & telephone number. If no: OK, thank you for your time. Your name and telephone number will not be added to our database.
Exit script 2: I’m sorry, you have identify, live, or present as the physical sex you were assigned at birth to take part in this study and therefore we won’t be able to use you at this time. However, I would like to put your name and telephone number you gave me into our database so that I can contact you about other studies coming up in the future. Is that OK? If yes, record name & telephone number. If no: OK, thank you for your time. Your name and telephone number will not be added to our database.
Exit script 3: I’m sorry, you have to have injected drugs in the past 12 months to take part in this study and therefore we won’t be able to use you at this time. However, I would like to put your name and telephone number you gave me into our database so that I can contact you about other studies coming up in the future. Is that OK? If yes, record name & telephone number. If no: OK, thank you for your time. Your name and telephone number will not be added to our database.
Exit script 4: Based upon your answers, it seems that we may already have a number of volunteers with very similar answers to yours. At this point we need to talk with people with some different characteristics. However, if we have cancellations or other slots open up, I may wish to call you back. Would it be okay if I kept your name, telephone number, and the information you provided in response to the eligibility questions until the end of this study? If yes, make notation. If no, Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, add to database. If no: OK, thank you for your time. Your name and any information you gave me will not be added to our database.
Exit script 5: I’m sorry, willingness to be audio taped is required in order to take part in this study and therefore we won’t be able to use you at this time. Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, add to database. If no: OK, thank you for your time. Your name and any information you gave me will not be added to our database.
Exit scrip t 6: I see...ok, we were hoping to complete this particular study between (Month/Date) and (Month/Date), so it looks like we won’t be able to schedule you at this time. Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, add to database. If no: OK, thank you for your time. Your name and any information you gave me will not be added to our database.
Attachment 3c – HET targeted screener
The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).
Public reporting burden for this collection of information is included in the interview minutes, 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, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).
OMB #0920-0222; Expiration Date: 03/31/2013
Sample screening script for HET targeted respondent contact by QDRL Laboratory Manager/QDRL Staff for
National HIV Behavioral Surveillance (NHBS) system, and questions regarding sexual identity for the
National Health Interview Survey (NHIS)
recruited through newspaper advertisement
Dial respondent’s telephone number [hereafter referred to as R] as indicated on audiotape recording.
Note: Speak only to R. If the number is answered by an answering machine, call back at another time.
Laboratory Manager: Good morning/afternoon, may I speak to (name)?
If R is not available or not at home, say, “Thank you” and try again at another time.
If the person who answered the phone (NOT R) asks, “Who is calling?” or “What’s this about?” say, “I am returning their call to me. I’ll try to reach them at another time.
If R has been successfully contacted, continue...
...Hello, my name is [Laboratory Manager’s name]. I am calling from the National Center for Health Statistics. You may remember that you responded to a flyer we placed in [LGBT Community Center Name] looking for adults aged 18 year and over to test survey questions on behaviors that might put someone ask risk for contracting HIV (the virus that causes AIDS).
Wait for acknowledgment, such as, “Oh, yes, I remember.”
...In order to determine if you are eligible for our study, I’ll need a few minutes of your time to ask some background questions. Answering these questions is completely voluntary. We are required by law to use your information for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you without your consent. Is this a good time to ask the questions or should I call back later?
If not a good time to talk, schedule a time to call back.
If good time to talk, continue and go to screener question 1.
1. How old are you? [If under age 18, go to exit script 1]
________________
2. What physical sex were you assigned at birth, male or female?
Male
Female
3. Do you identify, live, or present as a [man/woman]?
Yes
No [Go to exit script 2]
4. Have you injected drugs in the past 12 months?
Yes
No [Go to exit script 3]
5. Have you engaged in vaginal or anal sex with an opposite sex partner in the past 12 months?
Yes
No [Go to exit script 4]
6. Have you ever tested positive for HIV?
Yes
No
[If quota has been met, go to exit script 5. Otherwise continue].
7. How many years of education do you have?
9 or less 10 11 12 13 14 15 16 17 18 19
8. Are you Spanish, Hispanic or Latino?
Yes
No
9. What race or races do you consider yourself to be? You may indicate more than one race.
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
10. Would you say that your total household income last year was more or less than $50,000?
If MORE, ask: Would you say that your total household income last year was more or less than $80,000?
If LESS, ask: Would you say that your total household income last year was more or less than $25,000?
Entry Script:
...Based on your answers to the questions so far, we would like you to take part in our study. For this study we’d like you to come here to the National Center for Health Statistics in Hyattsville, MD. An interviewer will ask you questions on behaviors that may put someone at risk for contracting HIV, the virus that causes AIDS. Topics include injections drug use, sexual identity, sexual behavior, HIV testing, and antiretroviral medications. These questions will be used on large-scale surveys to help us understand more about patterns of HIV transmission in the United States. Then the interviewer will ask you to explain what you were thinking as you answered the questions. The interviewer will also ask you about your opinions of the questions. Your answers will help us find out if the survey questions will be easy for other people to answer. Everything you say will be kept private. With your permission, we would like to audio record your interview. The audio tape is a record of what we asked and what you said about the questions. Do you give permission to have your interview audio taped? Yes/No. [If no, go to exit script 6. Audio taping is essential for this project].
Do you have any questions at this point? Pause to answer questions. If (not/you have no other questions), then let’s get you on the schedule, ok? We will be interviewing (Day, Month/Date) through (Day, Month/Date) from 8 a.m. to 6 p.m. Looking at your schedule, when would you be available to participate? Schedule. [If date/times not available go to exit script 7.]
A reminder call will be made to you a few days in advance. Should you have any questions or need to change your appointment, please feel free to contact me [name] at [phone number]. Thank you for responding to our ad, and I look forward to seeing you here at (DATE/TIME) Get respondent to cite date & time if possible.
---------------------------------------------------------
Exit script 1: I’m sorry, you have to be over the age of 18 to take part in this study and therefore we won’t be able to use you at this time. However, I would like to put your name and telephone number you gave me into our database so that I can contact you about other studies coming up in the future. Is that OK? If yes, record name & telephone number. If no: OK, thank you for your time. Your name and telephone number will not be added to our database.
Exit script 2: I’m sorry, you have to identify, live, or present as the physical sex you were assigned at birth to take part in this study and therefore we won’t be able to use you at this time. However, I would like to put your name and telephone number you gave me into our database so that I can contact you about other studies coming up in the future. Is that OK? If yes, record name & telephone number. If no: OK, thank you for your time. Your name and telephone number will not be added to our database.
Exit script 3: I’m sorry, you cannot have injected drugs in the past 12 months to take part in this study and therefore we won’t be able to use you at this time. However, I would like to put your name and telephone number you gave me into our database so that I can contact you about other studies coming up in the future. Is that OK? If yes, record name & telephone number. If no: OK, thank you for your time. Your name and telephone number will not be added to our database.
Exit script 4: I’m sorry, you have to have engaged in vaginal or anal sex with an opposite sex partner in the past 12 months to take part in this study and therefore we won’t be able to use you at this time. However, I would like to put your name and telephone number you gave me into our database so that I can contact you about other studies coming up in the future. Is that OK? If yes, record name & telephone number. If no: OK, thank you for your time. Your name and telephone number will not be added to our database.
Exit script 5: Based upon your answers, it seems that we may already have a number of volunteers with very similar answers to yours. At this point we need to talk with people with some different characteristics. However, if we have cancellations or other slots open up, I may wish to call you back. Would it be okay if I kept your name, telephone number, and the information you provided in response to the eligibility questions until the end of this study? If yes, make notation. If no, Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, add to database. If no: OK, thank you for your time. Your name and any information you gave me will not be added to our database.
Exit script 6: I’m sorry, willingness to be audio taped is required in order to take part in this study and therefore we won’t be able to use you at this time. Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, add to database. If no: OK, thank you for your time. Your name and any information you gave me will not be added to our database.
Exit scrip t 7: I see...ok, we were hoping to complete this particular study between (Month/Date) and (Month/Date), so it looks like we won’t be able to schedule you at this time. Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, add to database. If no: OK, thank you for your time. Your name and any information you gave me will not be added to our database.
Attachment 3d – HET targeted screener/QDRL Database
The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).
Public reporting burden for 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, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).
OMB #0920-0222; Expiration Date: 03/31/2013
Sample screening script for HET targeted respondent contact by QDRL Laboratory Manager/QDRL Staff for
National HIV Behavioral Surveillance (NHBS) system, and questions regarding sexual identity for the
National Health Interview Survey (NHIS)
recruited through QDRL Respondent Database
Dial respondent’s telephone number [hereafter referred to as R] as indicated in the QDRL Respondent Database.
Note: Speak only to R. If the number is answered by an answering machine, call back at another time.
Laboratory Manager: Good morning/afternoon, may I speak to (name)?
If R is not available or not at home, say, “Thank you” and try again at another time.
If the person who answered the phone (NOT R) asks, “Who is calling?” or “What’s this about?” say, “I am returning their call to me. I’ll try to reach them at another time.
If R has been successfully contacted, continue...
...Hello, my name is [Laboratory Manager’s name]. I am calling from the National Center for Health Statistics. You may remember that you participated in a research study back in [date] testing questions on [topic].
Wait for acknowledgment, such as, “Oh, yes, I remember.”
…We are currently looking for adults aged 18 year and over to test survey questions on behaviors that might put someone ask risk for contracting HIV (the virus that causes AIDS) and I wondered if you might be interested in participating in our study.
If R indicates they are interested in participating continue…
If R indicates they are NOT interested in participating, go to exit script 8.
...In order to determine if you are eligible for our study, I’ll need a few minutes of your time to ask some background questions. Answering these questions is completely voluntary. We are required by law to use your information for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you without your consent. Is this a good time to ask the questions or should I call back later?
If not a good time to talk, schedule a time to call back.
If good time to talk, continue...
1. How old are you now? [If under age 18, go to exit script 1]
________________
2. What physical sex were you assigned at birth, male or female?
Male
Female
3. Do you identify, live, or present as a [man/woman]?
Yes
No [Go to exit script 2]
4. Have you injected drugs in the past 12 months?
Yes
No [Go to exit script 3]
5. Have you engaged in vaginal or anal sex with an opposite sex partner in the past 12 months?
Yes
No [Go to exit script 4]
6. Have you ever tested positive for HIV?
Yes
No
[If quota has been met, go to exit script 5. Otherwise continue].
7. How many years of education do you have?
9 or less 10 11 12 13 14 15 16 17 18 19
8. Are you Spanish, Hispanic or Latino?
Yes
No
9. What race or races do you consider yourself to be? You may indicate more than one race.
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
10. Would you say that your total household income last year was more or less than $50,000?
If MORE, ask: Would you say that your total household income last year was more or less than $80,000?
If LESS, ask: Would you say that your total household income last year was more or less than $25,000?
Entry Script:
...Based on your answers to the questions so far, we would like you to take part in our study. For this study we’d like you to come here to the National Center for Health Statistics in Hyattsville, MD. An interviewer will ask you questions on behaviors that may put someone at risk for contracting HIV, the virus that causes AIDS. Topics include injections drug use, sexual identity, sexual behavior, HIV testing, and antiretroviral medications. These questions will be used on large-scale surveys to help us understand more about patterns of HIV transmission in the United States. Then the interviewer will ask you to explain what you were thinking as you answered the questions. The interviewer will also ask you about your opinions of the questions. Your answers will help us find out if the survey questions will be easy for other people to answer. Everything you say will be kept private. With your permission, we would like to audio record your interview. The audio tape is a record of what we asked and what you said about the questions. Do you give permission to have your interview audio taped? Yes/No. [If no, go to exit script 6. Audio taping is essential for this project].
Do you have any questions at this point? Pause to answer questions. If (not/you have no other questions), then let’s get you on the schedule, ok? We will be interviewing (Day, Month/Date) through (Day, Month/Date) from 8 a.m. to 6 p.m. Looking at your schedule, when would you be available to participate? Schedule. [If date/times not available go to exit script 7.]
A reminder call will be made to you a few days in advance. Should you have any questions or need to change your appointment, please feel free to contact me [name] at [phone number]. Thank you for responding to our ad, and I look forward to seeing you here at (DATE/TIME) Get respondent to cite date & time if possible.
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Exit script 1: I’m sorry, you have to be over the age of 18 to take part in this study and therefore we won’t be able to use you at this time. However, I would like to keep your name and telephone number in our database so that I can contact you about other studies coming up in the future. Is that OK? If yes, keep in database. If no: OK, thank you for your time. Your name and any information you gave me will be deleted from our database.
Exit script 2: I’m sorry, you have to identify, live, or present as the physical sex you were assigned at birth to take part in this study and therefore we won’t be able to use you at this time. However, I would like to keep your name and telephone number in our database so that I can contact you about other studies coming up in the future. Is that OK? If yes, keep in database. If no: OK, thank you for your time. Your name and any information you gave me will be deleted from our database.
Exit script 3: I’m sorry, you cannot have injected drugs in the past 12 months to take part in this study and therefore we won’t be able to use you at this time. However, I would like to keep your name and telephone number in our database so that I can contact you about other studies coming up in the future. Is that OK? If yes, keep in database. If no: OK, thank you for your time. Your name and any information you gave me will be deleted from our database.
Exit script 4: I’m sorry, you have to have engaged in vaginal or anal sex with an opposite sex partner in the past 12 months to take part in this study and therefore we won’t be able to use you at this time. However, I would like to keep your name and telephone number in our database so that I can contact you about other studies coming up in the future. Is that OK? If yes, keep in database. If no: OK, thank you for your time. Your name and any information you gave me will be deleted from our database.
Exit script 5: Based upon your answers, it seems that we may already have a number of volunteers with very similar answers to yours. At this point we need to talk with people with some different characteristics. However, if we have cancellations or other slots open up, I may wish to call you back. Would it be okay if I kept your name, telephone number, and the information you provided in response to the eligibility questions until the end of this study? If yes, make notation. If no, Would it be okay if I kept your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, keep in database. If no: OK, thank you for your time. Your name and any information you gave me will be deleted from our database.
Exit script 6: I’m sorry, willingness to be audio taped is required in order to take part in this study and therefore we won’t be able to use you at this time. Would it be okay if I kept your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, keep in database. If no: OK, thank you for your time. Your name and any information you gave me will be deleted from our database.
Exit scrip t 7: I see...ok, we were hoping to complete this particular study between (Month/Date) and (Month/Date), so it looks like we won’t be able to schedule you at this time. Would it be okay if I kept your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, keep in database. If no: OK, thank you for your time. Your name and any information you gave me will be deleted from our database.
Exit script 8: I see...ok. Would it be okay if I kept your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, keep in database. If no: OK, thank you for your time. Your name and any information you gave me will be deleted from our database.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | krs0 |
| File Modified | 0000-00-00 |
| File Created | 2021-02-03 |