Form 1 Eligibility Screener

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

Attachment 3
Eligibility Screener

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

CMEP-RESPECT Eligibility Screener
This form should be completed (by CMEP staff, not the clients) for each individual who may be eligible to participate
in CMEP-RESPECT.

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 (Not eligible for CMEP)
6. Have you had anal sex with a male in the past 12 months (1 year)?
Yes
No (Not eligible for CMEP)
7. Have you ever completed the CMEP-RESPECT* (or insert local name for CMEP here) baseline interview? (Data
collector: Please confirm client’s response with your agency’s records)
Yes (Not eligible for CMEP)
No

8. If enrolled, enter the Outcome Monitoring Client ID here (after it has been assigned): ____ ____ ____ ____

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).