Screener

Form Approved

OMB No. 0920-0840

Expiration Date 02/28/2016

“Informing the Development of Mobile Apps for HIV Prevention, Treatment, & Care”

2a. Study Screener for People living with HIV/AIDS

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)

Participant Screening Form for Persons Living with HIV (PLWH) group

Date:
Screening ID:	Eligibility Status: No Yes

"Hi. I work with a project that is that funded by The Centers for Disease Control and Prevention (CDC) to develop a mobile application for HIV treatment. We are doing a research study to learn more about the treatment and care needs of persons who live with HIV. Can I ask you a few questions to see if you are eligible to take part in the study?

It will only take a minute or two. Some of the questions are personal, including questions about sexual activity. Taking part is up to you. Your responses will be kept private. You can refuse to answer a question or stop at any time. The information you give us will be joined with everybody else’s information so that we can describe the group, not individuals, taking part in the study. Are you interested?”

If you are eligible and decide to take part, you will receive $25 for a focus group session."

1. What is your age? _______ years old

[If under age 13 or over age 64] I’m sorry but you are not eligible to participate in this study at this time. You have to be at least 13 years old or less than 65 years old to be in the study. Thank you for your interest.

2. What is your gender?

Male

Female

Transgender

3. Are you comfortable speaking and reading English or Spanish, enough to participate in a program in English or Spanish?

No [Ineligible]

Yes

[If not comfortable in English or Spanish…] I’m sorry but you are not eligible to participate in this study at this time. We are recruiting men who are comfortable speaking and reading English or Spanish enough to participate in a program in English or Spanish. Thank you for your interest.

4. Have you ever been tested for HIV infection?

No

Yes …

What was your most recent result? Negative

Positive

Don’t know

If negative or unknown, I am sorry you do not qualify for this study but you may qualify for a different one.

5. Do you own or regularly use a Smartphone?

No

Yes …

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If eligible:

"You are eligible to take part in the study. There will be a 1.5 hour focus group session and you will receive $25 token of appreciation. Are you interested in taking part in the study?"

For those who are eligible and interested:

“Let me tell you a little more information about the study. Your visit involves completing some surveys and participating in a focus group session.

If you come to the first visit too late to complete the process in the time allotted, you will not receive a token of appreciation. If possible, you will be rescheduled for another time.

For those who self-report an HIV-positive serostatus at screening: We ask that you bring some documentation to confirm your HIV-positive serostatus. Please bring with you to your first visit a picture ID and ONE of the following items: a filled prescription bottle of HIV medication with your name on it; a letter from your physician, provider, or an agency (including a case manager) that states your name and your positive HIV status; AIDS Drug Assistance Program [ADAP] documentation; OR a positive test result with your name.

For those who are ineligible:

“I’m sorry but you are not eligible to take part in this study at this time. There are many possible reasons why people are not eligible to be in the study, reasons that were decided earlier by the researchers. We appreciate your interest in this study and willingness to consider helping to improve HIV care in our community. Thank you.”

For ineligibles, if applicable…

“We do, however, have other studies that you may be eligible to participate in. Would you like me to refer you to those studies?”

ELIGIBLE: ___ No ___ Yes, date of baseline visit __ __/__ __/__ __

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