Form Approved:
OMB No. 0920-XXXX
Expiration Date: 00/00/2014
Evaluating Locally-Developed HIV Prevention Interventions for African-American MSM in Los Angeles
Attachment 3b
Outreach Recruitment Assessment
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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)
Form Approved:
OMB No. 0920-XXXX
Expiration Date: 00/00/2014
Outreach Recruitment Assessment
Listed below are the questions staff should ask potential MyLife participants who are encountered during routine In The Meantime outreach activities or other similar events. Questions are listed in order of their corresponding variables noted on the Outreach Recruitment Log. Note: not all variables have a corresponding question. Record responses to the following questions on the recruitment form in accordance with these instructions.
Age: What is your age?
LAC Resident: In what county do you currently live?
Race/Ethnicity: What is your race or ethnicity?
Previous ITMT Group Participant: Have you ever attended a small, closed-group session at In The Meantime Men’s Group?
Sex Risk: In the past year, have you been either a bottom or a top with another man?
HIV Intervention: Have you participated in an HIV prevention intervention, either as an individual or in a group, in the past 3 months?
Gender: Do you identify as Male or Transgender?
Smoker: Do you currently smoke?
Doctor: Have you seen a medical doctor in the past 12 months?
8 Months: Do you plan to move out of LAC in the next 8 months?
Eligible for Study: No question.
Wants to Enroll: [If eligible for study] I would like to tell you more about a research study we are conducting to see if you are interested in taking part. Is that okay with you?
OUTREACH RECRUITMENT ASSESSMENT
Outreach event venue: ______________________
Outreach staff: __________________________
Outreach date: ____________________________
Time period:____________________________
# |
Age |
Reside LAC Y/N? |
Race/ ethnicity=Black? |
Prev. ITMT small group Y/N? |
Sex risk Y/N? |
HIV interv. past 3 mo Y/N? |
How identify? |
Current smoker Y/N? |
Doctor past year? |
Move from LAC in 8 mo? |
Eligible Y/N? |
Wants to enroll Y/N? |
1 |
|
Y N |
Y N |
Y N |
Y N |
Y N |
M T |
Y N |
Y N |
Y N |
Y N |
Y N |
2 |
|
Y N |
Y N |
Y N |
Y N |
Y N |
M T |
Y N |
Y N |
Y N |
Y N |
Y N |
3 |
|
Y N |
Y N |
Y N |
Y N |
Y N |
M T |
Y N |
Y N |
Y N |
Y N |
Y N |
4 |
|
Y N |
Y N |
Y N |
Y N |
Y N |
M T |
Y N |
Y N |
Y N |
Y N |
Y N |
5 |
|
Y N |
Y N |
Y N |
Y N |
Y N |
M T |
Y N |
Y N |
Y N |
Y N |
Y N |
6 |
|
Y N |
Y N |
Y N |
Y N |
Y N |
M T |
Y N |
Y N |
Y N |
Y N |
Y N |
7 |
|
Y N |
Y N |
Y N |
Y N |
Y N |
M T |
Y N |
Y N |
Y N |
Y N |
Y N |
8 |
|
Y N |
Y N |
Y N |
Y N |
Y N |
M T |
Y N |
Y N |
Y N |
Y N |
Y N |
9 |
|
Y N |
Y N |
Y N |
Y N |
Y N |
M T |
Y N |
Y N |
Y N |
Y N |
Y N |
10 |
|
Y N |
Y N |
Y N |
Y N |
Y N |
M T |
Y N |
Y N |
Y N |
Y N |
Y N |
11 |
|
Y N |
Y N |
Y N |
Y N |
Y N |
M T |
Y N |
Y N |
Y N |
Y N |
Y N |
12 |
|
Y N |
Y N |
Y N |
Y N |
Y N |
M T |
Y N |
Y N |
Y N |
Y N |
Y N |
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | gpo4 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |