Eligibility Screener - English word

Form Approved

OMB No. 0920-0840

Expiration Date: 02/29/2016

Testing Brief Messages for Black and Latino MSM

Attachment 2

Eligibility Screener--English

Public reporting burden of this collection of information is estimated to average 5 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)

Attachment 2: Eligibility Screener

Eligibility Screener

Introduction

“Thank you for your interest in the Messages4Men: Exploring New Health Information for Our Communities study, which is focused on learning more about the health behavior of men who have sex with men to help develop efforts to keep them healthy. We would like to let you know that funding for this study is provided by the Centers for Disease Control and Prevention. To find out if you are eligible for this study, we need to ask you a few questions. It should not take more than 5 minutes. Some of these questions are personal, including questions about sexual activity. Answering these questions is completely voluntary and you can refuse to answer a question or stop at any time. If you answer the questions and we determine that you are eligible, you will then be offered the opportunity to participate in the research study, which includes coming to [name of local site] to take part in a one-hour survey about similar topics. If you complete that longer survey, you will receive a $40 gift card as a token of appreciation. Would you like to continue to see if you are eligible for this study?”

1. In what month and year were you born? _______________

[If less than age 18, end screening and read the following ineligibility script]

[If under age 18…] I’m sorry but you are not eligible to participate in this study at this time. You must be at least 18 years old to be in the study. Thank you for your interest.

2. What is your gender?

Male

Female (Ineligible, skip to end)

Transgender (Ineligible, skip to end)

3. A. Are you Hispanic, Latino, or of Spanish origin? [check all that apply]

No, not of Hispanic, Latino, or Spanish origin (eligible if 4. Black or African American)

Yes, Mexican, Mexican American, Chicano (eligible)

Yes, Puerto Rican (eligible)

Yes, Cuban (eligible)

Yes, Other Hispanic, Latino or Spanish Origin (eligible)

3B. Are you any of the following Hispanic, Latino, or Spanish origins?

[check all that apply]

Brazilian

Colombian

Dominican

Ecuadorian

Guatemalan

Honduran

Peruvian

Salvadoran

Venezuelan

None of the above

Other Hispanic, Latino or Spanish origin (specify) _______________________

3C.Which racial group or groups do you consider yourself to be in? [check all that apply]

American Indian or Alaska Native (eligible if 3A. Yes, Hispanic, Latino, or of Spanish

Origin)

Asian (eligible if 3A Yes, Hispanic, Latino, or of Spanish Origin)

Black or African American (eligible)

Native Hawaiian or Pacific Islander (eligible if 3A. Yes, Hispanic, Latino, or of Spanish Origin)

White (eligible if 3A Yes, Hispanic, Latino, or of Spanish Origin)

4. In which of the following cities do you live or work?

Atlanta (ineligible, skip to end)

Chicago/Chicagoland (eligible, continue)

Ft. Lauderdale/Tri-County area (Dade, Broward, Palm Beach (eligible, continue)

Kansas City metro area (eligible, continue)

New York (ineligible, skip to end)

Other (specify)________________________ (ineligible, skip to end)

5. Have you ever been tested for HIV infection?

No 5A. What do you think your status is?

Negative

Positive

Yes 5B. What was your most recent result?

Negative

Positive

5D. What was the date of your diagnosis? ____Month ____ Year

[Must be at least six months ago or participant will be wait-listed; less than six months is ineligible at this time, continue to end]

Don’t know/Didn’t get test result

5C. What do you think your status is?

Negative

Positive

6. In the past twelve months, have you had sex with another man?

Yes

No (ineligible, skip to end)

7. In the past three months, with how many men have you had anal sex (as a top or bottom, insertive or receptive)?

None

One

Two or more

8. Think of the men you had anal sex with in the last three months. With how many of those men did you have unprotected anal sex (meaning any penetration without a condom)?

None

One

Two or more

9. In the past three months have you been a paid or volunteer staff member, peer leader, or participant for any of the following programs/projects that specifically addressed HIV prevention? [list by site]

Yes (ineligible, skip to end)

No

10. How did you hear or learn about this study?* (check all that apply)

  Online ad

Facebook

Adam4Adam

Other website:

  Mobile app

Grindr

Jack'd

Scruff

  Flyer or post card

  Newspaper or magazine ad

  Ad on the bus/subway

A friend or relative

  A health care or social service provider

  At an event

  Other:  _____________________

*Note:  Other options (e.g., names of specific websites, or newspapers) may be added for each site to reflect local recruitment activities.

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[If eligible…]

“You are eligible to participate in the study. If you are interested in participating, you will need to schedule an appointment to come to [name of local site] and take a survey. The entire visit will take about 90 minutes, and if you complete the survey, you will receive a $40 gift card as a token of appreciation. If you would like to take part or learn more, click below to schedule an appointment.”

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[If ineligible…]

“I’m sorry but you are not eligible to participate in this study at this time. There are many possible combinations of 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 health programs in our community. Thank you.”