CROSS-SITE Screening Instrument

0920-xxxx

Development and Testing of an HIV Prevention Intervention

Targeting Black Bisexually-Active Men

Attachment 3A

Screening Instruments

(Note: All sites use the same screening questions;

2 exceptions are highlighted in yellow)

Form Approved:

OMB No. 0920-XXXX

Expiration Date:

Cross-site Screening Instrument

Directions: Interviewer/screener read aloud all text in bold italicized typeface.

Hello and thank you for contacting the _____ Project. My name is _____________. How may I help you?

Can you tell me how you heard about _____?

If potential participant does not mention the ticket/coupon, ask him about it. Probe to see if he has participated in the study already.

To take part in the _____ Project, you must have a referral ticket or coupon. Do you have a ticket?

If NO

Explain that only men with tickets are eligible to participate. If potential participant says he does not have it with him, ask him to call back when he has the ticket in hand.

If YES

May I have your ticket number? One moment while I verify the number.

Verify that it is a valid ticket number and has not been voided for any reason. If not valid, discontinue screening.

Have you taken part in ______ before?

If NO: continue with screening.

If YES: explain that men can only take part once, and discontinue screening.

I want to take a moment to briefly explain what the _____ Project is. _____ is being conducted by ______ in partnership with ______ Organization.

The ______ Project is actually a study that is testing out the effectiveness of a health and wellness program designed specifically for Black men who have sex with both men and women.

I am going to need to ask you some questions to determine if you are eligible for the ______ Project, but first, I want to tell you a little about what we would be asking you to do if you decided to enroll in ______.

• The first thing we would ask you to do is to schedule an appointment to come to our office and take a survey on a computer. This will take about an hour and a half. As a token of appreciation we will give you $50.

• After you take the survey on the computer, we would ask you to return about one week later to take part in the _____ program. You will be asked to return for either ONE PRIVATE SESSION WITH A HEALTH COUNSELOR OR SIX PRIVATE SESSIONS WITH A LIFE COACH. Each of these sessions would last approximately an hour and a half to two hours.

• I can’t tell you ahead of time whether you would be asked to come for ONE or for SIX SESSIONS, but you must be willing to do either of these if you want to be a part of the ______ Project.

• We would do everything possible to schedule these sessions so that they accommodate your schedule.

• In addition to taking the survey and attending the private sessions, we would also ask you to take 2 more surveys later on. You would also receive tokens of appreciation for participating in these surveys.

Now that I’ve explained a little about ______ to you, does this sound like something you are interested in taking part in? Do you have any questions for me?

If YES: continue with screening.

IF NO: discontinue screening.

Great, first I need to ask you a few questions to determine whether or not you are eligible for the ______ Project. Your answers to these questions will be kept secure.

Can I begin asking you these questions now? Are you able to speak freely at this time?

1. Do you consider yourself to be a Black or African American male?

____ Yes (Eligible) (Skip to #2)

____ No

1a. What do you consider yourself? _____________________

(Interviewer, probe to determine if respondent considers a primary part of his racial or ethnic background to be Black/African American AND that he is a male. If he is not male, and he does not primarily identify as Black or African American, he is not eligible. Female to male transgender respondents and male to female transgender respondents are not eligible).

END INTERVIEW HERE.

EXPLAIN TO PARTICIPANT THAT THE STUDY IS FOR BLACK OR AFRICAN AMERICAN MEN. READ “NOT ELIGIBLE” script at end of screening form.

2. What is your age? ________

(If less than 18 years old, NOT ELIGIBLE. END INTERVIEW HERE. READ “NOT ELIGIBLE” script at end of screening form).

3. What County do you live in?

(If does not reside in eligible county/counties specified by study site, NOT ELIGIBLE)

PHMC:

____ (1) Philadelphia, Delaware, Chester, Montgomery, Bucks, Burlington, Camden, Gloucester, Salem (ELIGIBLE)

____ (2) Other (Specify County/State:____________________) (NOT ELIGIBLE)

NOVA:

____ (1) Cook, Lake, DuPage, Will (ELIGIBLE)

____ (2) Other (NOT ELIGIBLE)

CSU:

What County do you live in? _____________________

(If he does not reside in Los Angeles specified by study site, NOT ELIGIBLE)

What city in [insert county] do you live in?

4. How long have you lived in _________ county?

5. Are you currently in a committed relationship with anyone?

____ No

____ Yes

I have several questions to ask you about sex you have had with females, males and transgenders. For these questions, sex may include oral, vaginal or anal sex.

6. When was the last time that you had sex with a female? Would you say it was…

____Within the past 3 months

____3 to 6 months ago

____6 to 12 months ago, or

____more than 12 months ago (NOT ELIGIBLE)

____ never (NOT ELIGIBLE)

7. When was the last time that you had sex with a transgender female? By transgender female, I mean a person who was born male but who now lives their life as a female, and who may have changed their body through surgery or hormones to be more like a female. Would you say it was…

____Within the past 3 months

____3 to 6 months ago

____6 to 12 months ago, or

____more than 12 months ago

____ never

8. When was the last time you had sex with a male? Would you say it was…

____Within the past 3 months

____3 to 6 months ago

____6 to 12 months ago, or

____more than 12 months ago (NOT ELIGIBLE)

____ never (NOT ELIGIBLE)

In the next couple of questions, when I ask you about sex, I am only interested in knowing about times you had vaginal or anal sex. Do not include oral sex in your answers to these questions.

9. All together, how many people did you have vaginal or anal sex with in the past 3 months? Would you say…

____ None (See Probe Below) (NOT ELIGIBLE, SKIP TO QUESTION #11)

____ 1 (See Probe Below) (NOT ELIGIBLE, SKIP TO QUESTION #11)

____ 2

____ 3

____ 4 or more

[Interviewer Probe: if zero or only 1 sex partner reported in past 3 months, clarify for respondent the time period covered and that we are counting male, female and transgender partners.]

Example Probe: “Let me be sure I read this question clearly. “In this question, I am asking you to add up all of the people you had vaginal or anal sex with in the past 3 months. This includes males, females and transgender sex partners.”

10. Thinking about the times that you had vaginal or anal sex in the past 3 months, would you say that you used condoms…

____ Every time you had sex (See Probe Below) (NOT ELIGIBLE)

____ Almost every time

____ Some of the time

____ Rarely, or

____ Never

[Interviewer Probe: if ‘condoms used every time’, re-state question as follows…”Okay, so in the past 3 months, you used a condom every time that you had vaginal or anal sex with a male, female or transgender partner. Is this correct?”

11. Have you ever injected drugs with a needle? By drugs I mean illegal drugs…not the kind a doctor may have prescribed to you.

____ No

____ Yes

11a. [If yes] When was the last time that you injected drugs with a needle? (check corresponding box).

_____ More than 12 months ago (ELIGIBLE)
_____ Within the past 12 months (NOT ELIGIBLE)

12. Have you gone to see a doctor for any reason in the past 12 months?

___ No

___ Yes

Directions: Interviewer/Screener please review responses carefully to questions above to determine if respondent is eligible for the _____ Project. If any responses to items #1-#12 indicate “NOT ELIGIBLE”, then respondent is not eligible.

CSU asks 2 additional questions:

13. Have you ever been incarcerated in jail or prison for any length?

___No

___Yes

13a. [If yes] When was the last time that you were in jail or prison? (check corresponding box).

_____ 7 or more months ago (NOT ELIGIBLE)
_____ Within the past 6 months (ELIGIBLE)

NOT ELIGIBLE

Thank you for taking the time to call today, but unfortunately you are not eligible to participate in [insert local study name]. Please discard the ticket, because it is no longer valid. (If participant disagrees, inform him that your job is to ask the questions and determine eligibility based upon the responses. If he has any further questions, he can contact the Principal Investigator of the project).

ELIGIBLE

Based on your answers, you are eligible to participate in the _____ Project. At this time I would like to schedule an appointment for you to come in to complete the computerized survey. I will review the different days, times, and locations available, so that we may find an appointment that’s convenient for you.

Before I do that, I would like to make sure that you are you still interested in enrolling in _____ and would be glad to answer any questions you may have?

Do you have any questions for me?

Are you still interested in enrolling in _____?

Okay, let’s go ahead and set up your first appointment.

8