Community Screener - Screened Injection Drug Users and High-risk heterosexual individuals

Form Approved:

OMB No. 0920-new

Expiration Date: XX/XX/XXXX

Monitoring Outcomes of the Enhanced Comprehensive HIV Prevention Plan (ECHPP) Project

Attachment 3a

Eligibility Screener – Community Screener

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Public reporting burden of this collection of information is estimated to average 5 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, Project Clearance Officer, 1600 Clifton Road, MSD-74, Atlanta, GA 30333, ATTN: OMB PRA (0920-XXXX). Do not send the completed form to this address

Community Survey: Eligibility Screener

AUTO1 Date of Interview: __ __/ __ __ / __ __ __ __ AUTO2. Time Begin __ __:__ __  1AM  2PM

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

INT1. Interviewer ID __ __

INT2. Enter City __ __

INT3. Survey ID __ __ __ __ ___ ___ ___ ___

CONF1. Interviewer: The survey ID that you entered was [INT3]. Is this correct?

No……………..….. 0 Loop back to INT3

Yes……..……….… 1

INT4. Venue ID ___ ___ ___ ___

INT5. Event Number ___ ___ ___ ___

INT6 Enter the date of the recruitment event:

___ ___ / ___ ___/ ___ ___ ___ ___

^{M M / D D / Y Y Y Y}

INT7. Field Site ID ___ ___

CONF2. Interviewer: The field site ID that you entered was [Response to INT7]. Is this correct?

No……………..….. 0 Loopback to INT7

Yes……..……….… 1

_____________________________________________________

SAY: I’d like to thank you again for your interest in this health survey. Remember that all information you give me will be kept secure to the extent permitted by law and I will not ask for your name. First, I will ask you a few questions about yourself and then the computer will determine if you have been selected to participate in the health survey.

ES1. How old are you today? ___ ___ ___

[Refused = 777, Don't know = 999]

If Respondent is <18 years old, skip to END1.

ES2a. During 20xx, did you already complete at least part of the health survey that [Insert Project Name] is conducting? It could have been here or at another location.

No………………….……………….………...…0

Yes….……………………………….……......... 1

Known previous participant...……….……......... 2 Skip to END 1

Refused to answer………………………..…….. 7

Don't know.……………..……………….......... 9

ES2b. During 20xx, did you participate in [Local NHBS Project Name]? It could have been here or at another location.

No………………….……………….………...…0

Yes….……………………………….……......... 1

Known previous participant...……….……......... 2 Skip to END 1

Refused to answer………………………..…….. 7

Don't know.……………..……………….......... 9

ES3. Do you consider yourself to be Hispanic or Latino/a? [Interviewer: If respondent answers “Latino” or “Hispanic,” enter “Yes.”]

No………………….…………………………… 0 Skip to ES5 Yes………………………………………………1

Refused to answer……………………………… 7

Don't know……………..……………………... 9 Skip to ES5

ES4 . What best describes your Hispanic or Latino ancestry?

[READ CHOICES. CHECK ALL that apply.]

Mexican…………….…..……………………… 1

Puerto Rican………..…………………………... 2

Cuban…………...…………………..………….. 3

Dominican……...…………………..………….. 4

Some other ancestry (Specify_____)…………... 5

Refused to answer………....…………………… 7

Don't know………………………..……………. 9

ES5 . [GIVE RESPONDENT FLASHCARD A.] Which racial group or groups do you consider yourself to be in? You may choose more than one option. [READ CHOICES. CHECK ALL THAT APPLY.]

American Indian or Alaska Native…………… 1

Asian ..……………………..………………....... 2

Black or African American ……………..…….. 3

Native Hawaiian or Other Pacific Islander……..4

White ……………..……………………………. 5

Refused to answer………………………………7

Does not apply ………………………………..8

Don’t know……………………………………..9

ES6 . What county do you currently live in?_________________________________________

(List of eligible counties on computer)

IF “OTHER” COUNTY IS CHOSEN, ENTER THE COUNTY, THEN GO TO ES7.

IF RESPONDENT INDICATES COUNTY OUTSIDE OF THE MSA, SKIP TO END 1

ES7 . Do you consider yourself to be male, female, or transgender? [CHECK only ONE]

Male…………………………………………….. 1

Female …………………………………………. 2

Transgender ……………………………………. 3 Skip to END 1

Refused to answer………………………………  7

Don't know……………..……………………...  9

SAY: Now I’m going to ask you a few questions about drug use experiences you may have had. Remember, all your answers will be kept secure to the extent permitted by law.

ES8 . Have you ever in your life shot up or injected any drugs other than those prescribed for you?

By shooting up, I mean anytime you might have used drugs with a needle, either by mainlining, skin popping, or muscling.

No………………….……………………………  0 Skip to SAY box before ES12

Yes……………………………………………… 1 Refused to answer………………………………  7 Skip to SAY box before ES12

Don't know……………..……………………...  9

ES9 . When was the last time you injected any drug? That is, how many days or months or years ago did you last inject?

[Interviewer: Enter the number below. If today, enter 0]

Number __ ___ ___

[Refused = 777, Don't know = 999] Skip to Say box before ES12

ES9a . Interviewer: Was this days or months or years? [If today, enter “days”]

Days…………….. 1

Months…………….. 2

Years……………….. 3

IF Date > 12 months ago, skip to say box before ES12

ES10 .

Which drug do you inject most often?

[READ CHOICES. CHECK ONLY ONE]

Speedball – Heroin and cocaine together ……. 1

Heroin, by itself………………… …………….. 2

Cocaine, by itself……………………………… 3

Crack………………………………………….. 4

Crystal, meth, tina, crank, ice……………………... 5

Something else (Specify________________)…6

Refused to answer………....……………………  7

Don't know………………………..……………  9

ES11 . Step-by-step, tell me how you inject your drugs.

INTERVIEWER:

Description could include:

Tie off and find vein (IVDU)

Clean injection site

Register (IVDU)

Description OK……………………………… 1

Description Not OK………………………….. 2

SAY: The next questions are about having sex. Please remember your answers will be kept secure to the extent permitted by law.

ES12 . Have you had sex with a [insert “man” if respondent is female; insert “woman” if respondent is male] in the past 12 months?

No………………………………………………  0

Yes……………………………………………...  1

Refused to answer………....……………………  7

Don't know………………………..……………  9

ES12a .Did you have vaginal sex? By vaginal sex, I mean [insert “he put his penis in your vagina” if respondent is female; insert “you put your penis in her vagina” if respondent is male].

No………………………………………………  0

Yes……………………………………………...  1

Refused to answer………....……………………  7

Don't know………………………..……………  9

ES12b . Did you have anal sex? By anal sex, I mean [insert “he put his penis in your anus (butt)” if respondent is female; insert “you put your penis in her anus (butt)” if respondent is male]

No………………………………………………  0

Yes……………………………………………...  1

Refused to answer………....……………………  7

Don't know………………………..……………  9

CONF3.

Confirmation: Ask the following if ES12a and ES12b in (0, 7, 9):

“So, in the last 12 months, you only had oral sex with a [insert “man” if respondent is female; insert “woman” if respondent is male]? Is that correct?

If NOT correct, go back to ES12a .

If CORRECT, and if respondent is an IDU, go to ES13 .Else, skip to END1.

ES13. What is the highest level of education you completed?

[DO NOT read choices. Check only ONE.]

Never attended school….………………………….  00

Grades 1 through 8….…………………...………..  01

Grades 9 through 11..…………………….…….….  02

Grades 12 or GED...….……..…..…………………  03

Some college, Associate’s Degree, or

Technical Degree……………………………… 04

Bachelor’s Degree..………….…………….………  05

Any post graduate studies ………….…………….  06

Refused to answer………………..………………..  77

Don't know……..………………..………………..  99

ES14. What best describes your employment status? Are you:

[READ CHOICES. CHECK only ONE.]

Employed full-time………………….………….  01

Employed part-time…………………………….  02

A homemaker….……….…………………...…..  03

A full-time student…….…….…………………  04

Retired….………..……………………………...  05

Unable to work for health reasons …………….  06 Unemployed………..…………………………...  07

Other………..…………………………..............  08

Refused to answer………………………..……..  77

Don't know.……………..………………..........  99

Say: Next I'd like to ask you some questions about your income. By "income," I mean the total amount of money you earn or receive. This includes money other people share with you.

ES15. What was your household income last year from all sources before taxes?

Say: Please take a look at this card and tell me the letter that best corresponds to your monthly or yearly income.

GIVE RESPONDENT FLASHCARD B. DO NOT read choices.

Monthly Income Yearly Income

a. 0 to $417……………... a. 0 to $4,999……………….  00

b. $418 to $833………… b. $5,000 to $9,999………..  01

c. $834 to $1041…………c. $10,000 to $12,499..…… 02

d. $1042 to $1250………..d. $12,500 to $14,999……. 03

e. $1251 to $1667.……....e. $15,000 to $19,999……..  04

f. $1668 to $2082………..f. $20,000 to $24,999……..  05

g. $2083 to $2500……….g $25,000 to $29,999……..  06

h. $2501 to $2916……….. h. $30,000 to $34,999……..  07

i $2917 to $3333…………i $35,000 to $39,999……..  08

j. $3334 to $4167………. j. $40,000 to $49,999……..  09

k. $4168 to $4999………. k. $50,000 to $59,999……..  10

l. $5000 to $6,250…………l $60,000 to $74,999..….. 11

m. $6251 or more………... m. $75,000 or more………  12

Refused to answer………. ………………………………. 77 Skip to Say box before ES16

Don't know……..………………………………………..... 99

If ES15=77 or 99, skip to Say box before ES16

ES15a. Including yourself, how many people depended on this income? ___ ___

[MUST BE AT LEAST 1.]

[Refused = 77, Don't know = 99]

SAY: We’ve finished the first series of questions. Now the computer will determine whether you’ve been selected to participate in the survey.

ES16 . Interviewer: Is this person alert and able to complete the health survey in English or Spanish?

No……………………………………………. 0

Yes……………………………………………. 1

The computer will use an algorithm to determine if a respondent is eligible to participate as an IDU. A respondent is considered IDU if they have injected drugs in the previous 12 months.

If not an IDU, the computer will use an algorithm to determine if a respondent is eligible to participate as a HET. A respondent will be considered HET if participant is not IDU in previous 12 months; had vaginal or anal sex with person of opposite sex in past 12 months; and income and number of dependents on this income meet the 2009 HHS Poverty Guidelines. Additionally, HET must be 60 years of age or younger to be eligible.

If ES16 =0 and IDU, display ES16a ; then, go to END1.

If ES16 =0 and HET, display interviewer instruction ES16b , then go to END1.

ES16a Interviewer: Specify reason person not able to complete the interview:

Not alert………………………………………  1

Not able to complete in English or Spanish…...  2

Thought to be too young....……………………  3

Thought to not be IDU……………………….. 4

Other (specify _________)………..……………  5

ES16b Interviewer: Specify reason person not able to complete the interview:

Not alert………………………………………  1

Not able to complete in English or Spanish…...  2

Thought to be too young....……………………  3

Thought to be too old....……………………  4

Other (specify _________)………..……………  5

AUTO3 Time Eligibility Screener Ended: __ __:__ __ : __ __ [Military time HH:MM:SS]

END 1. If the participant IS NOT ELIGIBLE:

SAY: Thank you for answering these questions. Unfortunately, the computer has not selected you to participate in the health survey. Thank you again for your time.

End Interview.

End 2. If the participant IS ELIGIBLE:

SAY: Congratulations! The computer has selected you to participate in the health survey. Let me tell you about it. [Interviewer: Proceed with the consent process.]

Interviewer: Conduct the local IRB-approved consent process

CONSENTA. Do you agree to take part in the survey?

No………………….……………….………..... 0

Yes….……………………………….……......... 1

If CONSENTA=0 say: Thank you again for your time.

Community Survey: Eligibility Screener 18

December 9, 2011