Form Approved
OMB No. 0920-0775
Expiration Date 04/30/2011
ATTACHMENT 6c:
STUDY SCREENING INSTRUMENTS
HIV Partner Services
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
HIV Partner Services
Recruitment Screener
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 physicians to take part in a research study about HIV testing and prevention.
The purpose of the research is to learn physicians’ thoughts on a communication campaign being developed for providers who deliver medical care to persons living with HIV and involves participating in an interview. 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?
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 |
How many years have you been practicing medicine? ______________
< 2 |
|
TERMINATE |
2 or > |
|
CONTINUE |
4. What is your specialty?
Primary Care/ Family Medicine |
|
CONTINUE if recruiting for PCPs |
Internal Medicine |
|
GO TO Q4A-Q4B |
Infectious Disease |
|
CONTINUE if recruiting for infectious disease specialists |
Other |
|
TERMINATE |
ASK INTERNAL MEDICINE DOCTORS ONLY 4A. Do you have a sub-specialty? Yes _____ Go to Q4B No _____ CLASSIFY AS PCP AND CONTINUE
4B. What is your sub specialty? _____________________________________ [IF INFECTIOUS DISEASE - CLASSIFY AS INFECTIOUS DISEASE AND CONTINUE] [IF ANYTHING ELSE, TERMINATE ] |
5. In which of the following settings do you have your largest patient load?
[RECORD ALL THAT APPLY]
Private practice (By private practice, we mean a private physician’s office or group practice.) |
|
|
Public clinic |
|
|
Hospital |
|
|
Academic-based |
|
|
6. Of all the patients that you see, what percentage of your patients do you see in a private practice?
Private practice |
|
% |
[FOR IDs -- ATTEMPT AT LEAST 50%]
[FOR PCPs – MUST BE 50% OR TERMINATE]
PCPS CONTINUE WITH QUESTION 7; IDS SKIP TO QUESTION 13
Have you ever diagnosed a patient with HIV infection?
Yes |
|
|
No |
|
|
8. Have you ever treated a patient with HIV infection?
Yes |
|
|
No |
|
|
9. In the past 12 months, how many patients have you treated who are living with HIV?
__________
What is the name of your practice, hospital, clinic, or HMO system?
___________________________________
[MAX 2 PER PRACTICE OR SYSTEM]
Please tell me your age. _____________
[ATTEMPT MIX]
[Record Gender]
Male |
|
Female |
|
[ATTEMPT MIX]
Segment PCPs as Treat vs. Non-Treat based on chart below:
|
Q. 7 Ever diagnose? |
Q. 8 Ever treat? |
Q. 9 Number of patients treated in last 12 months? |
Treat |
Yes |
Yes |
3 or more |
Non-Treat |
Yes or No |
Yes or No |
0-2 |
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 a communications campaign for providers who deliver medical to persons living with HIV 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 [$150 for PCP OR $250 for IDS] 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 my questions. At this time 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.
IDS’ ONLY
On average, how many new cases of HIV do you diagnose per month?
__________
Note: Record response and continue – this is not an eligibility criteria
Thinking about your current caseload, how many of the patients that you regularly see in your practice are living with HIV or AIDS?
__________
[MUST BE 50 OR MORE TO QUALIFY]
What is the name of your practice, hospital, clinic or HMO system?
_____________________
[MAX 2 PER PRACTICE OR SYSTEM]
Please tell me your age. ___________
[Attempt Mix]
17. Record gender.
Male |
|
Female |
|
[Attempt 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 a communications campaign for providers who deliver medical to persons living with HIV 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 [$150 for PCP OR $250 for IDS] 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 my questions. At this time 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.
Interviewer: ____________________
Supervisor Confirm: ____________________
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Form Approved |
| Author | Jennifer Uhrig |
| File Modified | 0000-00-00 |
| File Created | 2021-02-01 |