Form 1 Eligibility Screener

“Community-based Organization (CBO) Monitoring and Evaluation
Project of WILLOW (CMEP-WILLOW)”

Attachment 3
Eligibility Screener

Form Approved
OMB No. 0920-XXXX
Exp. Date: XX/XX/20XX

CMEP-WILLOW Eligibility Screener
This form should be completed by staff (not the client) for each individual enrolled into
WILLOW.
1. Recruitment site ______________________
2. Staff ID ________________________
3. Today’s date:

__ __ /__ __ /__ __ __ __

(MM/DD/YYYY)

4. How old are you? ________________
(Client must be at least 18 years old to be eligible for CMEP.)
5. What was your sex at birth?
Male
Female
6. What is your gender?
Male (Not eligible for CMEP)
Female
Transgender – Male to Female
Transgender – Female to Male
7. Have you tested positive for HIV?
Yes
No (Not eligible for CMEP)
8. When did you first test positive for HIV? __ __ /__ __ /__ __ __ __

(MM/DD/YYYY)

(Client must have known about her positive HIV status for at least 6 months.)
9. If enrolled (client is eligible AND agrees to participate), enter client ID here:
____ ____ ____ ____

Public reporting burden of this collection of information is estimated to average 2 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74,
Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).