Screening Form (SUNY)

HIV/AIDS Risk Reduction Interventions for African-American

Heterosexual Men

0920-10CM

Attachment 3a

Data Collection: Screening Form – SUNY

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

HIV/AIDS Risk Reduction Interventions for African-American

Heterosexual Men

Data Collection: Screening Form – SUNY (Attachment 3a)

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 persons 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 (0920-09XX)

Screening Form

Interviewer initials: ____ ____ ____ Screening date: ____ ____ / ____ ____ / ____ ____

	Not Eligible	Eligible
1. Are you between the ages of 18 and 45 years?	_____NO	_____YES
2. Do you consider yourself to be Black or African American?	_____NO	_____YES
3. Would you be able to answer questions in English?	_____NO	_____YES
4. Have you had any health concerns or worries in the last 3 months?	_____NO	_____YES
5. Have you received services at this barbershop at least once a month for the last 3 months?	_____NO	_____YES
6. Do you consider yourself to be a Man or a Woman?	_____WOMAN	_____MAN
7. Thinking back over the last 3 months, would you say that you have had no female sexual partners, 1 female sexual partner, or 2 or more female sexual partners?	_____0-1 PARTNERS	_____2+ PARTNERS
8. Was there at least one time in the last 3 months when you did not use a condom with your female partners?	_____NO (or no female partners)	_____YES
9. Have you ever been told by a doctor or other health professional that you have HIV?	_____YES	_____NO
10. Thinking back over the last 5 years, have you had anal or oral sex with another man?	_____YES	_____NO
11. Have you been to see a doctor in the last 3 months for any type of health concern?	_____NO	_____YES
12. Have you injected illicit/illegal drugs with a needle in the last 3 years?	_____YES	_____NO
13. In the last 12 months, have you been part of an HIV or drug use research study?	_____YES	_____NO

9. Is respondent eligible?

_____NO-MISSED AT LEAST ONE ELIGIBLE ITEM FROM QS 1-3, 6-10, 12-13 [END CONTACT]

_____NO-RESPONSES IMPLY ELIGIBILITY, BUT UNABLE TO PROVIDE INFORMED CONSENT [END CONTACT]

_____ NO- RESPONSES IMPLY ELIGIBILITY, BUT ENROLLMENT LOG INDICATES THAT INDIVIDUAL PARTICIPATED IN PHASE I ACTIVITIES [END CONTACT]

_____YES [SEE BELOW]

11. Based on what you have told me, you are eligible for participating in this project. May I spend a few minutes telling you a little more about what we are doing here today?

_____NO [END CONTACT]

_____YES [COMPLETE CONSENT / LOCATOR/ ENROLLMENT, THEN COMPLETE #12 WITH ID]

12. Was client enrolled in the study?

_____NO

_____YES [STUDY