Registration

Form Approved

OMB No. 0920-0840

Expiration Date: 02/29/2016

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

Attachment 1b

Field Performance Study Registration

Public reporting burden of this collection of information is estimated to average 15 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 Registration

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AUTO1. Date of Registration: __ __ / __ __ / __ __ __ __

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

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

We will now ask you some questions to obtain your contact information. This information will not be shared or used for any other research purposes. Questions marked with a red asterisk (*) are required questions that you must answer to move forward.

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Email verification

During the study we may send you emails with important information such as reminders to complete more health surveys and electronic gift certificates. Please provide us with an email address where you would like to receive this information.

QS1. What is your email address?* ____________________

Please hit the ‘Next’ button to submit your email address.

If QS1 is not answered, display “Please enter a valid email address to proceed.” and loop back to enter the email address.

Allow the participant 2 attempts to enter an email address. If he does not answer on the second attempt skip to End1.

Now, please check your email account. You should have received an email from us with a code.

What is the code?* ____________________

If the code is correct, display “Thank you for entering the correct code.” and go to QS2.

If the code is not correct, display “Sorry, that is not the correct code. Please re-enter the code to proceed.” and loop back to enter the code.

Allow the participant 3 attempts to enter the code. If he does not enter the correct code on the third attempt skip to End1.

Telephone number information

During the study we may call you to talk about your HIV testing practices and test results. To make sure that you can receive our calls, please provide us with a valid telephone number.

QS2. On which telephone number can you receive calls?* ____________________

If QS2 is not answered, display “Please enter a valid telephone number to proceed.” and loop back to enter the telephone number.

Allow the participant 2 attempts to enter a telephone number. If he does not answer on the second attempt skip to End1.

During the study we may send you text messages with important information such as reminders to complete more health surveys. To make sure that you can receive our text messages, please provide us with a valid telephone number.

QS3. On which telephone number can you receive text messages?* ____________________

If QS3 is not answered, display “Please enter a valid telephone number to proceed.” and loop back to enter the telephone number.

Allow the participant 2 attempts to enter a telephone number. If he does not answer on the second attempt skip to End1.

Now, please check your telephone. You should have received a text message from us with a code.

What is the code?* ____________________

If the code is correct, display “Thank you for entering the correct code.” and go to QS4.

If the code is not correct, display “Sorry, that is not the correct code. Please re-enter the code to proceed.” and loop back to enter the code.

Allow the participant 3 attempts to enter the code. If he does not enter the correct code on the third attempt skip to End1.

Mailing address information

We will be sending you a package containing free rapid HIV home test kits by regular mail. Therefore, we are asking you to provide us with a valid mailing address. This address does not need to be your home address. You may choose to receive packages at a family member’s address, a friend’s address or a P.O. Box, as long as you can timely, securely and privately receive these packages. If you cannot provide a mailing address you will not qualify to participate in our study. As mentioned earlier, this information is private and it will not be shared or used for any other research purposes.

QS4. What is your mailing address?*

Address 1: ____________________

Address 2: ____________________

City: ____________________

State: ____________________

Zip: ____________________

If QS4 is not answered, display “Please enter a valid mailing address to proceed.” and loop back to enter the mailing address.

Allow the participant 2 attempts to enter a mailing address. If he does not answer on the second attempt skip to End1.

Name or alias information

During the study we will not connect your name with any survey. Please provide us with your name, or if you prefer, a nickname, alias or name of your choice that we can use throughout the study to communicate with you. This name will also be displayed on the package mailed to you as part of this study. You will need to know by the name on the package that it is for you.

QS5. What is your name, nickname, alias or name of choice?* ____________________

If QS5 is not answered, display “Please enter your name, nickname, alias or name of choice to proceed.” and loop back to enter the name.

Allow the participant 2 attempts to enter a name. If he does not answer on the second attempt skip to End1.

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End 1. If the participant does not provide the required information:

Thank you for your interest in this health study. Unfortunately, the system did not select you to participate any further. Any contact information you provided us above will be destroyed.

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

If you have any questions or comments, you may contact the Principal Investigator, Dr. Patrick Sullivan of Emory University, at (404) 727-2038.

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

End survey.

End 2. If the participant provides the required information:

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

The first step is to create your secure account on the study website. Your login ID will be the email address you provided above and your password will be the code that was sent to you in the text message. After logging in, you will then be able to complete a baseline health survey, at the end of which you can specify how you want to receive a $20 gift card.

Please click on the following link to set up an account and complete the baseline health survey: [link to study website].

Continue to study website to set up an account and complete the baseline survey.

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