Follow-up Survey

Form Approved

OMB No. 0920-0840

Expiration Date: 02/29/2016

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

Attachment 1e

Field Performance Study Follow-up Survey

Public reporting burden of this collection of information is estimated to average 10 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 Follow-Up Survey

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AUTO1. Date of Follow-up Survey: __ __ / __ __ / __ __ __ __

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

AUTO2. Time Began Follow-up Survey __ __:__ __:__ __ [24 Hour time HH:MM:SS]

Thank you for participating in our study! We will now ask you some questions to learn more about your experience of using the rapid HIV home test kits. You may choose to not answer any questions that make you feel uncomfortable.

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Section A. Kit usage information

If the participant checked only one response in KU1, skip to FS3.

FS1. You mentioned that you used [insert response(s) from KU1] from the package we sent you as part of this study. In what order did you use these items? Please order the options below with 1 being the first test you conducted, 2 the second, and 3 the third.

[ ] Oral fluid HIV test

[ ] DBS specimen collection kit

[ ] Finger-stick blood HIV test

Display appropriate response options based on what the participant checked in KU1.

FS2. Did you use these items within 2 days (48 hours) of each other?

No

Yes

I prefer not to answer

FS3. Where did you test yourself using the rapid HIV home test(s)?

At my house

At a friend’s or sex partner’s house

At work

In a car

Other location (Specify___________)

I prefer not to answer

Section B. Experience with the referral support system

FS4. Did you call the study’s toll-free number 1-(800)-___-____ at any time after receiving the package?

No

Yes

I prefer not to answer

If FS4 = “No”, skip FS5 and FS6.

FS5. Why did you call the study’s toll-free number? Check all that apply.

To ask questions about the study

To ask about how to use the oral fluid HIV test (OraQuick)

To ask about how to interpret the results of my oral fluid HIV test (OraQuick)

To ask about how to use the finger-stick blood HIV test (Sure Check)

To ask about how to interpret the results of my finger-stick blood HIV test (Sure Check)

To ask about how to collect a blood sample and/or dry and package the filter paper card in the DBS specimen collection kit

To get a referral to a local testing service

To get some counseling (or talk to someone)

Other reason (Specify___________)

FS6. How helpful was the information you received?

Very helpful

Somewhat helpful

Not helpful

Not helpful at all

I prefer not to answer

Section C. Testing circumstances

FS7. Do you think you kept the rapid HIV home test kits at a temperature between 36◦ - 86◦ Fahrenheit from the time you received the package until you used the tests?

No

Yes

Don’t know

FS8. Do you think the temperature in the place where you tested yourself was between 36◦ - 86◦ Fahrenheit during the time you conducted the tests?

No

Yes

Don’t know

FS9. Do you think you kept the filter card at a temperature between 36◦ - 86◦ Fahrenheit from the time you received the package until you mailed the filter card with your blood sample?

No

Yes

Don’t know

Ask Section D only if the participant checked “Oral fluid HIV test (OraQuick)” in KU1.

Section D. OraQuick experience

The next questions are about your experience using the oral fluid HIV test (OraQuick). As a reminder, for this test you had to swab your gums with a flat pad to collect an oral fluid sample.

FS10. How easy was it to use the oral fluid HIV test (OraQuick)?

Very easy

Somewhat easy

Somewhat difficult

Very difficult

I prefer not to answer

FS11. How confident are you that you collected your oral fluid sample according to the instructions?

Very confident

Somewhat confident

Not very confident

Not confident at all

I prefer not to answer

FS12. Did you read the test results between 20 - 40 minutes after inserting the flat pad of the device into the vial?

Yes

No, I read results before 20 minutes

No, I read results after 40 minutes

I prefer not to answer

FS13. How confident are you that you correctly interpreted your test results after using the oral fluid HIV test (OraQuick)?

Very confident

Somewhat confident

Not very confident

Not confident at all

I prefer not to answer

FS14. How much do you trust the results from the oral fluid HIV test (OraQuick)?

I completely trust the results

I somewhat trust the results

I do not trust the results

I do not trust the results at all

I prefer not to answer

FS15. Did you have any problems using the oral fluid HIV test (OraQuick)?

No

Yes

I prefer not to answer

If FS15 = “No” or “I prefer not to answer”, skip to FS17.

FS16. What kind of problems did you encounter? ____________________ (open-ended)

FS17. Did someone you know (for example your partner, friend, or family member) help you conduct or interpret the results from the oral fluid HIV test (OraQuick)?

No

Yes

I prefer not to answer

Ask Section E only if the participant checked “DBS specimen collection kit” in KU1.

Section E. DBS experience

The next questions are about your experience using the DBS specimen collection kit. As a reminder, for this you had to stick your finger with a lancet and collect drops of blood in 5 circles on a filter card.

FS18. How easy was it to collect your blood sample on the filter card?

Very easy

Somewhat easy

Somewhat difficult

Very difficult

I prefer not to answer

FS19. How confident are you that you collected your blood sample on the filter card according to the instructions?

Very confident

Somewhat confident

Not very confident

Not confident at all

I prefer not to answer

FS20. How confident are you that you dried and packaged the filter card according to the instructions?

Very confident

Somewhat confident

Not very confident

Not confident at all

I prefer not to answer

FS21. Did you have any problems collecting the blood sample and/or drying and packaging the filter card?

No

Yes

I prefer not to answer

If FS21 = “No” or “I prefer not to answer”, skip to FS23.

FS22. What kind of problems did you encounter? ____________________ (open-ended)

FS23. Did someone you know (for example your partner, friend, or family member) help you collect the blood sample and/or dry and package the filter card?

No

Yes

I prefer not to answer

Ask Section F only if the participant checked “Finger-stick blood HIV test (Sure Check)” in KU1.

Section F. Sure Check experience

The next questions are about your experience using the finger-stick blood HIV test (Sure Check). As a reminder, for this test you had to prick your finger with a lancet and collect a small blood sample in the tip of a sampling device.

FS24. How easy was it to use the finger-stick blood HIV test (Sure Check)?

Very easy

Somewhat easy

Somewhat difficult

Very difficult

I prefer not to answer

FS25. How confident are you that you collected your blood sample in the tip of the sampling device according to the instructions?

Very confident

Somewhat confident

Not very confident

Not confident at all

I prefer not to answer

FS26. Did you read the test results between 15 - 20 minutes after pushing the sampling device all the way through the foil into the vial?

Yes

No, I read results before 15 minutes

No, I read results after 20 minutes

I prefer not to answer

FS27. How confident are you that you correctly interpreted your test results after using the finger-stick blood HIV test (Sure Check)?

Very confident

Somewhat confident

Not very confident

Not confident at all

I prefer not to answer

FS28. How much do you trust the results from the finger-stick blood HIV test (Sure Check)?

I completely trust the results

I somewhat trust the results

I do not trust the results

I do not trust the results at all

I prefer not to answer

FS29. Did you have any problems using the finger-stick blood HIV test (Sure Check)?

No

Yes

I prefer not to answer

If FS29 = “No” or “I prefer not to answer”, skip to FS31.

FS30. What kind of problems did you encounter? ____________________ (open-ended)

FS31. Did someone you know (for example your partner, friend, or family member) help you conduct or interpret the results from the finger-stick blood HIV test (Sure Check)?

No

Yes

I prefer not to answer

Ask Section G only if the participant checked “Oral fluid HIV test (OraQuick )” AND “Finger-stick blood HIV test (Sure Check)” in KU1.

Section G. Comparing OraQuick & Sure Check

FS32. Which rapid HIV home test would you prefer to test yourself with again in the future?

Finger-stick blood HIV test (Sure Check)

Oral fluid HIV test (OraQuick)

Depends upon the cost

I would use both equally

I would not use either of these tests

FS33. Which rapid HIV home test was the easiest to use?

Finger-stick blood HIV test (Sure Check)

Oral fluid HIV test (OraQuick)

Both were equally easy to use

Neither of them was easy to use

FS34. Which rapid HIV home test result do you trust the most?

Finger-stick blood HIV test (Sure Check)

Oral fluid HIV test (OraQuick)

I trust the results from both equally

I do not trust results from either of these tests

FS35. Which rapid HIV home test would you recommend to your friends or sex partners?

Finger-stick blood HIV test (Sure Check)

Oral fluid HIV test (OraQuick)

I would recommend both equally

I would not recommend either of these tests

Section I. Token of appreciation information

We will now ask you some questions about how you would like to receive $10 for completing this survey.

FS36. How would you like to receive your $10 token of appreciation? Choose only one method.

Cash token of appreciation through PayPal (requires a bank account)

Amazon.com electronic gift card (will be sent by email)

I do not wish to claim my token of appreciation

If FS36 = “Cash token of appreciation through PayPal”, then go to FS37.

If FS36 = “Amazon.com electronic gift card”, then skip to FS39.

If FS36 = “I do not wish to claim my token of appreciation” then skip to End.

Receiving your token of appreciation by PayPal requires that you have a bank account. You will NOT be required to provide information about your bank account to this survey, only to PayPal. If you do not have bank account, please return to the previous question and select another option for your token of appreciation.

We will send your PayPal token of appreciation to the email address you provided during registration, unless you prefer for us to use another email address.

FS37. Do you want us to use the email address [insert email address from QS1] to send your PayPal token of appreciation?

Yes

No

If FS37 = “No”, then go to FS38 else skip to End.

FS38. Please enter the new email address where you would like us to send your PayPal token of appreciation. ____________________

We will send your electronic gift card to the email address you provided during registration, unless you prefer for us to use another email address.

FS39. Do you want us to use the email address [insert email address from QS1] to send your electronic gift card?

Yes

No

If FS39 = “No”, then go to FS40 else skip to End.

FS40. Please enter the new email address where you would like us to send your electronic gift card. ____________________

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Thank you for completing our survey! Your response is very important to us. 

Your token of appreciation or gift card will be sent to you by email at the address you indicated earlier. If you have not received your token of appreciation within 10 days, please first check your spam filter/junk email folder, and then email us at (email address).  Please send this email from the email address you provided during registration i.e. [insert email address from QS1].

End survey.

AUTO3. Time Ended Follow-up Survey: __ __:__ __: __ __ [24 Hour time HH:MM:SS]