Emergency Dept. Routine HIV Testing Screener

Form Approved

OMB No. 0920-0775

Expiration Date 04/30/2011

ATTACHMENT 6a:

STUDY SCREENING INSTRUMENTS

Routine HIV Testing in Emergency Departments

Statement of burden for study screening instrument

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 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: PRA (0920-0775)

Formative Research, Evaluation Planning, and Evaluating HIV Prevention Social Marketing Campaigns

Routine HIV Testing in Emergency Departments

Recruitment Screener

Introduction

Hello, my name is _______________ and I’m from (name of company). We are calling on behalf of RTI International, a non-profit research organization, and the Centers for Disease Control and Prevention. We are not selling or promoting any product. We are calling to recruit emergency medicine physicians to take part in a research study about HIV testing and prevention.

The purpose of the research is to learn physicians’ thoughts on HIV testing in emergency medicine and involves participating in an interview on the subject of HIV testing.

To see if you are eligible for this study, I need to ask you some questions. If you are eligible and choose to be in the study, all of your comments will be kept private. In appreciation for your participation, you will be reimbursed for your time, effort, and travel expenses.

My questions will only take a few minutes. May I proceed?

1. First, does any member of your household or immediate family work for, or receive any compensation from:

A market research company _____

An advertising agency or public relations firm _____

The media (TV/radio/newspapers/magazines) _____

The CDC _____

MAX. 1 OR 2  A pharmaceutical company _____

[IF “YES” TO ANY  GET SPECIFICS AND HOLD.

RECRUITMENT FACILITY SHALL CONTACT RTI TO DETERMINE WHETHER TO RECRUIT THE INDIVIDUAL]

2. Have you attended a focus group discussion or interview in the last six months about HIV? By focus group, we mean an informal, round-table discussion, conducted by a facilitator, in which you were asked your professional opinions regarding something related to HIV?

Yes		TERMINATE
No		 CONTINUE

3. How many years have you been practicing medicine? ______________

< 2		TERMINATE
2 or >		CONTINUE

3. Are you currently in a residency program?

Yes		TERMINATE
No		 CONTINUE

5. Are you currently working full time in an emergency room setting?

Yes		 CONTINUE
No		TERMINATE

6. What is your specialty?

_________________________

7. Do you order HIV tests on your patients?

Yes		 CONTINUE
No		TERMINATE

8. How many HIV tests do you order in a month?

0-1		TERMINATE
2-5		 CONTINUE
6-20		 CONTINUE
21 or more		 CONTINUE

9. How many people living with HIV do you see per month?

0-1		TERMINATE
2-5		 CONTINUE
6-20		 CONTINUE
21 or more		 CONTINUE

10. Please tell me your age. _____________

[MIX REQUIRED]

11. [Record Gender]

Male
Female

[ATEMPT MIX]

Invitation:

Thank you for answering all of my questions. As I mentioned earlier, we are conducting a research study on behalf of the CDC regarding HIV testing and prevention and would like to hear your professional views. In order to hear them first-hand, we would like to invite you to take part in an informal, personal interview. The interviews are being scheduled on [DAYS/DATE TBD] at a time that would be convenient for you [GIVE AVAILABLE TIMES]. The discussion will last about 1 hour and you may find the discussion interesting and informative. No one will attempt to sell you anything and no one will call on you for other studies as a result of your participation in this study. As a token of appreciation, you will receive $200 at the time of the interview. This is an important research effort and we hope that you will be part of it. We can only invite a few physicians in your area to take part. Can we schedule your attendance?

Closing for Ineligible Participants:

Thank you for answering all of my questions. You are not eligible to be in this study because... We value your interest in this research study. Thank you for being willing to help us.

Information Sheet

We are asking for your contact information only for the purpose of sending you a reminder letter and giving you a call to remind you of your interview. We will destroy all contact information upon conclusion of the interviews.

NAME: _______________________________________________________

PRACTICE NAME: _______________________________ (RECRUIT MAX 2 PER)

ADDRESS: _________________________________________________

CITY: _________________________________________________

ZIP CODE: _________________________________________________

EMAIL _______________________________________________________

What is the best time to reach you? What is the best telephone number to reach you at that time?

BEST TIME TO BE REACHED:________________________________________

BEST PHONE NUMBER: __________________

Is there another time and number we can try if we miss you?

ALTERNATE PHONE NUMBER:

Your participation in this study is very important. If for some reason you will not be able to attend, please let us know right away. You can call us anytime at [insert phone number], and if we are not here, please leave a message. Thank you.

Interviewer: ____________________

Supervisor Confirm: ____________________