Pre-screening

Form Approved:

OMB No. 0920-xxxx

Expiration Date: xx/xx/xxx

Critical Thinking and Cultural Affirmation (CTCA): Evaluation of a Locally Developed HIV Prevention Intervention

Attachment 3

Pre-Screening Form

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)

Pre-Screening Form

Recruiter: Hi, my name is _______. I want to talk to you about a study called Critical Thinking and Cultural Affirmation: HIV Prevention and Intervention for African American Men who have Sex with Men. The study is about a program that address the issues that affect black men who have sex with men, including culture, sexuality, and HIV/AIDS. Can I ask you a few questions about whether you might be able to participate in the study? It will only take a few minutes.

If Respondent says No:

Recruiter: Thanks for your time. [Hand the man an information card.]

If Respondent says Yes:

Recruiter: Great!

Recruiter asks the following questions:

Question	Qualifying Answer
Are you between the ages of 18 and 55?	Yes.
What do you consider to be your primary race/ethnicity?	Black, African American, etc.
What is your gender?	Male
Do you smoke?	Any; this is a distracter question.
Are you a resident of the Chicago area? If yes, do you have a specific plan to move away from the area within the next 6 months?	Yes. No.
Have you had anal or vaginal sex with a man or a woman in the past 30 days?	Yes.
Have you had anal sex with a man in the past year?	Yes.

If Respondent does not meet eligibility criteria:

Recruiter: Unfortunately, at this time, you are not eligible to take part in the study but thank you for your time. [Hand the man an information card.]

If Respondent meets preliminary eligibility:

Recruiter: You are potentially eligible to be in the study. Let me tell you a little more about it. The study is evaluating a program called Critical Thinking and Cultural Affirmation, which is a group HIV prevention and intervention program for men who have sex with men and it addresses issues of gender, culture, sexuality, and health behaviors. Participation in the study is confidential. Does that sound like something you are interested in?

Respondent: Yes.

Recruiter: Great. Do you have about 10 minutes to complete a full screening at this time?

Respondent: Yes.

Recruiter: (Continue with the full screening, beginning with question 7 of the Full Screening Script)

Respondent: No.

Recruiter: That’s okay. For more information about the study and to determine if you meet all of the criteria for participating, you can call this number [recruiter hands the man a study contact card and points to study office number] or even just stop by here [point to study office address]. It will take about 10 minutes to complete the full screening. Participation in the study is confidential.

Any questions?

Respondent: No.

Recruiter: Okay. Thanks for your time.

3