Prevention is Care Screener

Form Approved

OMB No. 0920-0775

Expiration Date 04/30/2011

ATTACHMENT 6b:

STUDY SCREENING INSTRUMENTS

Prevention is Care (PIC)

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

Prevention is Care (PIC)

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 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 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?

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

2. 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]

7. On average, how many new cases of HIV do you diagnose per month?

___________________

[IF LESS THAN “1”, TERMINATE for PCPs]

[This question is not a requirement for infectious disease specialists]

Note: You may find that the Infectious Disease Specialists are not diagnosing HIV because they are getting referrals after the patient has already been diagnosed. If they say none, probe to see if this is the reason, if it is, it is OK to take them. Primary Care physicians need to diagnose at least 1 per month to qualify.

7. Thinking about your current caseload, how many of the patients that you regularly see in your practice are living with HIV or AIDS?

________________

[FOR IDs -- MUST BE “50” OR GREATER TO QUALIFY]

[FOR PCPs – ATTEMPT “50” OR GREATER; TERMINATE IF LESS THAN 20]

7. What is the name of your (practice, hospital, clinic, or HMO system)?

___________________________________

[MAX 2 PER PRACTICE OR SYSTEM]

7. Please tell me your age. _____________

[ATTEMPT MIX]

7. [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: ____________________