Attachment 3a Screening form

“Preventing HIV Risk Behaviors among Hispanic Adolescents”

Attachment 3a: Care Giver and Adolescent Screening Form (English Language)

Form Approved

OMB No. 0920-XXXX

Expiration Date XX/XX/20XX

Screening Form

Letter ID#:________________

Date:________________________

Facilitator/Interviewer #:_______

Name of Parent that spoke to (if different than Primary Caregiver):

_____________________________________________________________________

Public reporting burden of this collection of information is estimated to average 3 minutes per response. 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)

Screening Criteria For Primary Parent

1. Adolescent is self-identified as Hispanic by

primary caregiver. Yes No

2. Adolescent living with a primary caregiver

who is willing to participate. Yes No

3. Family has plans (tentative or firm) to move

out of the South Florida area during the next

two years. Yes No

4. Primary caregiver has been hospitalized for

psychiatric reasons. Yes No

Screening Criteria for Adolescent

5. Adolescent is currently in the 9^th grade

(Not a problem if the adolescent is or has

repeated the 9^th grade). Yes No

6. Adolescent is willing to participate. Yes No

7. Adolescent has been hospitalized for psychiatric

reasons. Yes No

Screening Outcome:

***If the parent or adolescent answers “No” to questions 3, 4, 6, or 7 the family is deemed ineligible***

Family is eligible to participate. Yes No