Eligibility Screener

Form Approved

OMB No. 0920-0840

Expiration Date: 02/29/2016

Evaluation of Rapid HIV self-testing in MSM (eSTAMP): Field Performance Study

Attachment 1a

Eligibility Screener

Public reporting burden of this collection of information is estimated to average 3 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 (0920-0840)

Part 3 Eligibility Screener

____________________________________________________

AUTO1. Date of Eligibility Screener: __ __ / __ __ / __ __ __ __

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

AUTO2. Time Began Eligibility Screener __ __:__ __:__ __ [24 Hour time HH:MM:SS]

Thank you for your interest in our study. First, we have a few questions to determine if you’re eligible. Questions marked with a red asterisk (*) are required questions that you must answer to move forward.

____________________________________________________

ES1. How old are you? __ __

If ES1 <18 skip to End1

ES2a. What U.S. State or U.S. Territory do you live in?

[DROP DOWN MENU LISTS STATES AND TERRITORIES and “I do not live in the United States” for non-U.S. States or Territories]

ES2b. What zip code do you live in?

__ __ __ __ __

If ES2 ≠ one of the study cities, continue questions but End= End 1

ES3. Do you consider yourself Hispanic or Latino?

No

Yes

I prefer not to answer

ES4. What is your race? Please mark all that apply.

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

ES5. What was your sex at birth?

[Check only one]

Male

Female

Intersex/Ambiguous

I prefer not to answer

ES6. Do you consider yourself to be male, female, or transgender?

[Check only one]

Male

Female

Transgender

Other (Specify _____)

I prefer not to answer

If ES5 or ES6 ≠ “Male”, continue questions but End=End 1

The next question is about having sex with other men. For this question, "unprotected anal sex" means you put your penis in his anus (butt), or he put his penis in your anus (butt), without using a condom or not using it the whole time.

ES7. Have you had unprotected anal sex with a man in the past 12 months?

No

Yes

I prefer not to answer

If ES7 ≠ “Yes”, continue questions but End=End1

ES8. Have you ever been diagnosed with a bleeding disorder?

No

Yes

I don't know

I prefer not to answer

If ES8 = “Yes”, “I don’t know” or “I prefer not to answer”, continue questions but End=End1

The next questions are about your HIV status. Please remember that your answers are anonymous and will be kept private.

ES9. Have you ever been tested for HIV? An HIV test checks whether someone has the virus that causes AIDS.

No

Yes

I prefer not to answer

If ES9 = “No”, go to End 2

If ES9 = “Yes” go to ES10

If ES9 = “I prefer not to answer”, go to End 1

ES10. What was the result of your most recent HIV test?

Negative

Positive

Never obtained results

Indeterminate I prefer not to answer

If ES10 = “Positive” or “I prefer not to answer”, go to End 1.

If ES10 = “Negative” or “Never obtained results” or “Indeterminate”, go to ES11

ES11. Are you taking antiretroviral medications to prevent HIV?

No

Yes

I don't know

I prefer not to answer

If ES11 = “Yes”, “I don’t know” or “I prefer not to answer”, skip to End 1

If ES11 = “No” then go to ES12

ES12. Have you ever been part of an HIV vaccine trial?

No

Yes

I don't know

I prefer not to answer

If ES12 = “Yes”, “I don’t know” or “I prefer not to answer”, skip to End 1

If ES12 = “No” then proceed to registration process

____________________________________________________

End 1. If the participant is not eligible:

Thank you for your interest in this health study. Unfortunately, the system did not select you to participate any further.

If you want to learn more about HIV, where to get more information, or where to get tested in your area, please click on the following link: http://www.aidsvu.org/

To get more information about HIV, please visit: www.cdc.gov/hiv

Otherwise, you can close your browser window. Thank you for your time.

End survey.

End 2. If the participant is eligible:

Congratulations! You are eligible to participate in this health study.

Please click on the following link to complete the registration process and enroll into this study: [link to registration]. Thank you for your time.

Continue to registration.

AUTO3. Time Ended Eligibility Screener: __ __:__ __: __ __ [24 Hour time HH:MM:SS]