Clinic Screener - HIV Positive Screened Individuals

Form Approved:

OMB No. 0920-new

Expiration Date: XX/XX/XXXX

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

Attachment 3c

Eligibility Screener – Clinic Survey

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, MS D-74 Atlanta, GA 30333, ATTN: OMB PRA (0920-XXXX). Do not send the completed form to this address.

Clinic 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. Participant ID __ __ __ __ ___ ___ ___ ___

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

No……………..….. 0 Loop back to INT3

Yes……..……….… 1

INT4. Facility ID ___ ___ ___ ___

CONF2. Interviewer: The facility ID that you entered was [Response to INT4]. Is this correct?

No……………..….. 0 Loopback to INT4

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 MMP 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 about your HIV status.”

ES8. What was the result of your most recent HIV test? [DO NOT Read choices, check only ONE.]

Skip to End 1

Negative………………….……………………..  1 Preliminary

Preliminary or confirmed positive………….......  2

Never obtained results………………….….........  3

Skip to End 1

Indeterminate…………..……………..…………  4 Refused to answer…………...….……………….  7

Don't know…...…………………………..........  9

ES9. When did you learn you were HIV-positive?

___ ___ / ___ ___/ ___ ___ ___ ___

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

ES10. Have you visited this clinic or another facility to received HIV medical care within the last 12 months?

No………………….………………..………...…0

Yes….……………………………….……......... 1

Refused to answer………………………..…….. 7

Don't know.……………..……………….......... 9

ES11. (If has not accessed care in last 12 months and was diagnosed more than 1 year ago) Did you visit this clinic or another facility to get HIV medical care more than one year ago at some point after you were diagnosed?

No………………….………………..………...…0

Yes….……………………………….……......... 1

Refused to answer………………………..…….. 7

Don't know.……………..……………….......... 9

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

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

Eligibility is calculated by the computer based on eligibility criteria as defined in the protocol

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, as applicable.

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

No………………….……………….………..... 0

Yes….……………………………….……......... 1

If CONSENTA=0, skip to DECLINE.

Flashcards

FLASHCARD A

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

Clinic Eligibility Screener 13

December 9, 2011