Form No number No number Screening Questionnaire

“Exploring HIV Prevention Communication Among Black Men Who Have Sex with Men in New York City: Project BROTHA”

0920-XXXX

Attachment 3a. Screening Questionnaires

Form Approved

OMB No. 0920-XXXX

Expiration Date XX/XX/20XX

“Exploring HIV Prevention Communication Among Black Men Who Have Sex with Men in New York City: Project BROTHA”

0920-XXXX

Screening Questionnaires

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-XXXX)

D ate___/____/___

ID Number _______________

Screener initials __________

Project BROTHA Screening Questionnaire

Instructions: Read statements in bold italics to the potential participant. Write responses directly on this form. Do not write the participant’s name or contact information on this form. Contact information must be recorded separately on the contact sheet and the participant’s ID number written on this form.

1. "Thank you for calling. Where did you receive our number from?”

   1. Card you received

   2. Internet ad

2. If card, ask for the number on upper right hand corner: _______________

   1. What is your home zip code? _______________________

Go to About the Study

ABOUT THE STUDY

“We are a group of researchers from CHEST, a health research center affiliated with the City University of New York. We are working with GMAD, a community-based organization located in Harlem. We’re interested in talking with black men and other men in their social circles about their thoughts on HIV prevention and HIV testing. We also want to know how you communicate with your friends, associates, and others about these issues. If you choose to participate in this study, you will be asked to come to one of our offices for the first appointment. You will also be invited to come in on one more occasion, 3 months after your first appointment. Questions about drug and alcohol use, sexual behavior and mental health will be asked. You may also receive HIV testing, if you wish at either or both appointments.

The first visit may last up to 2 hours and the follow-up visit is shorter. You will be paid $60 for the first completed survey and interview, and $30 for the follow-up. You can earn up to $90 for your full participation in the study.

Because your involvement with the project occurs over 3 months, we will ask you for your name and contact information. Information that links your name to your data will be kept in a locked file cabinet. This link will be destroyed after the data have been entered into a computer and re-checked. If you agree to participate, all information about you will be stored securely.

Do you have any questions? Are you still interested in participating?”

_____ 1) Yes Continue with screener, go to B.

_____ 2) No Thank caller.

B. “Do you feel comfortable right now answering a few quick personal questions so that I can determine whether you are eligible to participate? It will take less than 5 minutes.”

1) Yes “Good. Let’s start with a few brief questions.”

2) No--wants to be screened later "Is there a better time for you to call us, or would you like to leave us a phone number where we can call you?"

Schedule the new call.

____ 3) No--doesn’t want to be screened. Thank caller.

C. "How old are you?” Years old If under 18/over 64, thank caller and end call

D. “Do you consider yourself Black?”

Yes No

During recruitment of first 100 BMSM, answer must be “yes”. If no, thank caller and end call. During recruitment of 200 other MSM, either answer is OK.

E. "What ethnic group do you most identify yourself with?"

1) African American

2) African (native) Specify country: ________________ 3) Caribbean

4) Latino Specify: ________________

5) Mixed race Specify: ________________

7) Other Specify: ________________

8) Unknown

F. “Have you had sex with another man within the last 3 months?”

Yes No

G. “What do you consider your sexual identity?”

1) Gay

2) Bisexual

3) Same Gender Loving

4) Straight

5) Other

“I just need to ask a few quick questions about HIV testing.”

H. “Have you ever been tested for HIV”

Yes No

H1. “If yes, how many months or years ago was your last test?”

More than 1 year ago_________ 0 to 12 months ago

If 0 to 12 months ago, thank caller and end call

I. “Do you know at least 2 other men who have sex with men?”

Yes No

If No, thank caller and end call.

J. If Yes, “do you discuss HIV prevention and testing issues with other men who have sex with men in your social circle?”

Yes No

Assuming the participant is no younger than 18 and not older than 64,

and has answered up to this point, then participant is eligible.

If ineligible, thank caller for his/her time.

K. “It looks like you are eligible for the study. Are you still interested in participating?”

1) Yes (Go to O)

0) No (Go to Y)

L. “If you choose to participate in this study, you will be asked to visit our Chelsea or Harlem sites. CHEST is in Chelsea; GMAD is in Harlem. Would you be able to do this?”

____1) Yes

____0) No INELIGIBLE

L1. Which site would you prefer to visit?

_____ 1) Chelsea (CHEST)

_____ 2) Harlem (GMAD)

M. "We would like to set up a time when you can meet with one of our interviewers. Both sites are near a number of subway lines and Penn Station. Is there anything that might make it especially difficult for you to come to any sessions (i.e. out-of-state college, transportation)? The first session will last about two hours and the follow-up session in 3 months will take less time”

_____ 1) Yes Ask for details

__________________________________________________________________________________________________________________________________________________________

_____ 2) No

N. “The staff are men and women who are well-trained and sensitive to our participants’ concerns. Do you have any preference to meeting with either a man or woman?”

_____ 1)Yes

Prefer: ______ Male

______ Female

“We will make every effort to meet your needs.”

_____ 2) No

X “It will be necessary for us to have the ability to contact you over the term of this research project. In order to contact you, we will need your address and telephone number. When we do contact you by phone, we will never mention the project name or what the study is about. To protect your information, we will only mention our name, phone number, and that we are from City University of New York (CUNY). Can you please give a number we can contact you at?

_____ 1) Yes Fill out top half of locator information

_____ 2) No Participant is not eligible

Please hold on while I get an appointment for you. It might take a few minutes.”

“Thanks. Now let’s schedule your first appointment.”

Site (Circle one only.): CHEST GMAD

Time & Date:__________________________ Interviewer’s Name:______________________

Room:_____________________________ Computer#:_________________

WRITE CONTACT INFORMATION ON CONTACT SHEET

For those who agree to participate:

“Thank you for being willing to help us with our study. Again I want to remind you that all the information you gave is strictly secure. Do you have a pen handy because I would like to give you the address and your appointment time? You are scheduled for an appointment with __(RA Name)_______ on ___(date)__________at_(time)_________o’clock. CHEST is located at 250 West 26^th Street, 3^rd Floor Suite 300, between 7^th and 8^th Avenues. You can either take the 1 to 28^th St. and 7^th Ave. or the C or E to 23 rd St. and 8^th Ave. OR GMAD is located at 103 East 125^th Street, Suite 503 between Lexington and Park Avenues. You can either take the 2, 3, 4, 5, or 6 trains to 125^th St. and, after you exit, walk towards Park Avenue. If you need to contact us before your interview you can call CHEST at 212-206-7919 or GMAD at 212-828-1697.

For your first appointment, we need you to bring the following items:

• A recent Photo I.D. preferably with your date of birth

• An appointment or date book, if you have one, to help us schedule your next appointment.

• ALSO, please be advised that we cannot conduct the interview if you are under the influence of alcohol or recreational drugs. If you show up for your appointment under the influence, we will have to reschedule your appointment.

Y If eligible, but doesn’t want to participate: "Thank you for taking the time to talk with me today. You don’t have to answer the next question if you do not wish, but it would be useful for us to know why you decided not to participate?"

(Provide referral information and other community services as requested.)

1) Not interested in study topic

2) Study topic too sensitive/personal

3) Scheduling difficulties

4) Concerned about confidentiality

___5) Other

Staff Name: ______________________________________

Screening Date:____/____/_____

The Mini-Mental Status Examination

Task	Instructions	Scoring
Date Orientation	"Tell me the date?" Ask for omitted items.	One point each for year, season, date, day of week, and month	5
Place Orientation	"Where are you?" Ask for omitted items.	One point each for state, county, town, building, and floor or room	5
Register 3 Objects	Name three objects slowly and clearly. Ask the patient to repeat them.	One point for each item correctly repeated	3
Serial Sevens	Ask the patient to count backwards from 100 by 7. Stop after five answers. (Or ask them to spell "world" backwards.)	One point for each correct answer (or letter)	5
Recall 3 Objects	Ask the patient to recall the objects mentioned above.	One point for each item correctly remembered	3
Naming	Point to your watch and ask the patient "what is this?" Repeat with a pencil.	One point for each correct answer	2
Repeating a Phrase	Ask the patient to say "no ifs, ands, or buts."	One point if successful on first try	1
Verbal Commands	Give the patient a plain piece of paper and say "Take this paper in your right hand, fold it in half, and put it on the floor."	One point for each correct action	3
Written Commands	Show the patient a piece of paper with "CLOSE YOUR EYES" printed on it.	One point if the patient's eyes close	1
Writing	Ask the patient to write a sentence.	One point if sentence has a subject, a verb, and makes sense	1
Drawing	Ask the patient to copy a pair of intersecting pentagons onto a piece of paper.	One point if the figure has ten corners and two intersecting lines	1
Scoring	Total Possible Points		30

Protocol for Participant Screening regarding Psychological Symptoms

&

Psychological Symptom Screening

BMSM

1. The staff assessor will conduct this screening procedure in person immediately after he confirmatory screening (for those who are eligible). Both screening procedures will be conducted after obtaining verbal consent to be screened.

2. The assessment administrator will verbally conduct the psychological symptoms screening procedure (see attached), which was developed from the DSM-IV. If a participant answers ‘yes’ to any particular item, the administrator will probe for the most recent occurrence of that experience and seek additional information through simple probes such as “Can you tell me a little more about that?” or “What was that like?”. The administrator will make written notes of all responses and comments.

3. After asking all of the questions, the assessment administrator will examine the responses. Action should then proceed as follows:

No ‘yes’ responses: Proceed with administration informed consent followed by remaining research protocols.

One or more ‘yes’ responses: The staff member will have the individual speak with a clinically-trained staff member. The assessor, the Project Director, and the clinical staff person will then make a decision as to whether the participant should be enrolled in the study.

Psychological Symptom Screening

Read script:

Thanks for answering those questions again. Before we confirm you are eligible, we have a few more questions related to stress and how you feel. May I have your permission to ask you these questions?

Thank you. Sometimes when people get really stressed, they might experience things they don’t normally experience. I’m going to ask if some of these things have ever happened to you. If you say yes, I’ll ask for a little more detail.

Note: To determine if reported symptoms may be organic, ask whether the respondent was taking any drugs or medications at the time the symptoms were experienced, whether they were drinking a lot, or physically ill.

Question	If Yes, ask date of last occurrence	Comments/Notes – Provide Examples
Did you ever hear things that other people couldn’t hear, such as noises, or the voices of people whispering or talking? (Were you awake at the time?)	Y Date: N
Did you ever have visions or see things that other people couldn’t see? (Were you awake at the time?) Note: Distinguish from an illusion, i.e., a misperception of a real external stimulus.	Y Date: N
Did you ever have a period of time in which your thoughts were racing for no apparent reason, and you couldn’t slow them down? Or did you have days when you were so keyed up that you felt like you didn’t need to sleep. Note: Distinguish from possible effects of recreational drug use.	Y Date: N
Did it ever seem that you thought people were taking special notice of you, and other people did not think that was happening to you? Did you ever feel you were receiving special messages, like from the TV, radio or newspaper?	Y Date: N
Did you ever feel that parts of your body had changed or stopped working? What about strange sensations in your body or on your skin? (If YES, What did the doctor say?)	Y Date: N
Did you ever feel that you were especially important in some way, or that you had powers to do things that other people couldn’t do?	Y Date: N
Did you ever feel that you had committed a crime or done something terrible for which you should be punished?	Y Date: N
Have you felt that people were going out of their way to give you a hard time or were trying to hurt you?	Y Date: N