Screener

Form Approved

OMB No.

Expiration Date

Web-based HIV Behavioral Surveillance System

Eligibility Screener

Public reporting burden of this collection of information is estimated to average 1 minute 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, Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA 0920-NewDo not send the completed form to this address.

The information in this report to the Centers for Disease Control and Prevention (CDC) is authorized by law (Sections 304 and 306 of the Public Health Service Act, 42 USC 242b and 242k). Response to this survey is voluntary. Your cooperation is necessary for the understanding and control of HIV/AIDS. Information in CDC’s HIV/AIDS surveillance system that would permit identification of any individual on whom a record is maintained, is collected with a guarantee that it will be held in confidence, will be used only for the purposes stated in the assurance on file at CDC, and will not otherwise be disclosed or released without the consent of the individual in accordance with Section 308(d) of the Public Health Service Act (42 USC 242m(d)).

Web-based HIV Behavioral Surveillance System: Eligibility Screener

_____________________________________________________

Thank you for your interest in our survey. Please note the following information:

1. Your answers are confidential: we don’t have any information about who you are beyond the questions you answer.

2. This survey includes some personal questions. You can choose to not answer any questions that make you feel uncomfortable.

3. If you agree to be in this study, you will first be screened to see if you qualify to be in the study. If you qualify, you will be given the opportunity to complete the survey.

{Consent screen displays}

CONSENT. I have read the information above. I consent to participate in the survey. {CONSENT}

I consent to participate in the survey……….……………….………..... 0

I do not consent to participate in the survey...……………….……........ 1

AUTO1. Date of Interview: __ __/ __ __ / __ __ __ __ {IDATE }

^{(M M / D D / Y Y Y Y )}

AUTO2. Time Began Eligibility Screener __ __:__ __ :__ __ [24 Hour time HH:MM:SS] {START_ELIG}

ES1. How old are you? _ _ _ {AGE}

IF ES1 < 18, skip to End 1.

IF ES1 = (777 or 999), skip to End 1.

ES2. During 20xx, did you already complete at least part of the <name of survey>? {E_PART}

No 0

Yes 1

I prefer not to answer 7

Don't know 9

ES3. Do you consider yourself to be Hispanic or Latino? {HISPANIC}

No 0

Yes 1

I prefer not to answer 7

Don't know 9

ES4. Which racial group or groups do you consider yourself to be in? Check all that apply:

American Indian or Alaska Native 1 {RACEA}

Asian 2 {RACEB}

Black or African American 3 {RACEC}

Native Hawaiian or Other Pacific Islander 4 {RACED}

White 5 {RACEE}

I prefer not to answer 7 {RACEF}

Does not apply 8 {RACEG}

Don’t know 9 {RACEH}

ES5. What U.S. State or U.S. Territory do you live in? {STA_TERR}

[DROP DOWN MENU LISTS ELIGIBLE STATES AND TERRITORIES and “I don’t live in the United States” for non-U.S. States or Territories]

[Don’t Know=99]

ES6. What [county/municipality] do you live in? {COU_MUN}

[DROP DOWN MENU LISTS ELIGIBLE COUNTIES]

[Refuse to answer = 77; Don’t Know=99]

If ES6 =(77 or 99), then skip to End 1. If ES6 ≠ 77 and ES6 ≠ 99, then proceed to DM-1.

ES7. What city do you live in? {CITY}

[Refused = 77777, Don't know = 99999] __ __ __ __ __

[DROP DOWN MENU LISTS ELIGIBLE CITIES]

[Refuse to answer = 77; Don’t Know=99]

ES8. What zip code do you live in?

[Refused = 77777, Don't know = 99999] __ __ __ __ __

ES9. Do you consider yourself to be male, female, or transgender? {GENDER}

Male  1

Female  2

Transgender  3

I prefer not to answer  7

Don't know  9

If ES9 ≠ 1, skip to End 1.

ES9a. Have you ever had vaginal sex (penis in the vagina) or anal sex (penis in the butt) with a woman? {E_EVRMSW}

No 0

Yes 1

I prefer not to answer 7

Don't know 9

ES9b. Have you ever had oral sex (mouth on the penis) or anal sex (penis in the butt) with a man? {E_EVRMSM}

No 0

Yes 1

I prefer not to answer 7

Don't know 9

If ES9b = (7 or 9), skip to End 1

If ES2 = 0 and ES9 = 1 and ES9b = 1 and ES5 ≠ (’Other’ or 99), then go to End 2.

Else, go to End 1.

End 1. If the participant is NOT ELIGIBLE:

Thank you for completing the survey. Unfortunately, you were not selected to participate any further. Thank you for your time.

End Interview.

End 2. If the participant is ELIGIBLE:

AUTO3. Time Ended Eligibility Screener: __ __:__ __ : __ __ [24 Hour time HH:MM:SS] {END}