Motion Comic Screener

Form Approved

OMB No. 0920-0840

Expiration Date: 02/19/2016

Attachment 1a. Study Screener

Development of a Motion Comic for HIV/STI Prevention Among Young People – ages 15-24-Phase 2

Study Screener

Public reporting burden of this collection of information is estimated to average 1minute 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 (0920-0840)

MOTION COMIC SCREENING TOOL

A. DEMOGRAPHICS.

1. How old are you? _____ years

2. What sex are you? _____ male _____ female _____ transgender

3. Are you Hispanic or Latino? _____ yes _____ no

4. What is your race? (Check all that apply) _____ American Indian or Alaska Native

_____ Asian

_____ Black or African American

_____ Native Hawaiian or Other Pacific Islander

_____ White

5. How do you identify your sexuality? _____ Homosexual/gay/lesbian

_____ Heterosexual/straight

_____ Bisexual

_____ Not sure

IF NOT ELIGIBLE, THANK YOU FOR YOUR TIME

IF ELIGIBLE,

Please provide us with your contact information so that we can schedule you for a future focus group

Name ____________________________________

Contact Phone Number #1 ____________________________________

Contact Phone Number #2 ____________________________________

ID # ____________