Screener

FORM APPROVED

OMB NO.: 0920-0840

EXPIRATION DATE: 2/28/2016

Eligibility Screener: Process

Attachment 4

Public reporting burden of this collection of information is estimated to average 2 minute 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)

NORC at the University of Chicago

Eligibility Screener

Main Project Title: Formative Research to Assess Injection Behaviors Among Young Persons Who Inject Drugs in Rural and Suburban Settings

Principal Investigator: David Rein, PhD

NORC Field Staff Script: Thank you for your interest in the IDU study. In order to determine your eligibility to participate in this study, I would like to ask you four questions. Do I have your permission to ask you these four questions?

Yes

No

NORC Field Staff Instruction and Script: If potential participant say yes, NORC field staff should respond “Thank you. I will now ask you the four questions (below).” If the potential participant says no, NORC field staff should respond “Thank you for your interest in this study. Unfortunately, to participate, I need to determine your eligibility. If you change your mind, you are welcome to come back to this location and answer the four eligibility questions.”

NORC Field Staff Instruction and Script: If potential participant responds yes to all four questions, NORC field staff should respond, “You are eligible for participation in the study. I will now go through the verbal informed consent (next page) to tell you more about the study and what is expected of you for you participation as well as what you will be compensated for your participation in this study.” If potential participant responds no to any of the four questions, NORC field staff should respond, “Thank you for your interest in this study. Unfortunately, you are not eligible to participate at this time.”

NORC at the University of Chicago

Eligibility Screener Questions

Main Project Title: Formative Research to Assess Injection Behaviors Among Young Persons Who Inject Drugs in Rural and Suburban Settings

Principal Investigator: David Rein, PhD

Eligibility Questions

1. Are you between the ages of 18 and 29 years old?

Yes No

2. Have you injected street drugs within the last 12 months?

Yes No

3. Are you able to complete a survey in English?

Yes No

4. Do you have a photo ID with you (to confirm your name and year of birth)?

Yes No

3