Discordant partners screeners - English

Form Approved

OMB No. 0920-0840

Expiration date: 02/29/2016

“Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment”

2e. HIV-Discordant Partners 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)

iQual Insight Screener SDP SDPHID

Date: Eligible

Recruiter Initials_ PLWH ID

DO NOT WRITE NAMES OR CONTACT INFORMATION ON THIS FORM

CALLING R FOR RECRUITMENT:

Hi, my name is [Interviewer]? Who am I speaking with? I’m calling from [RSS/Emory]. I got your name from your partner. He said you might be interested in a research study that we are doing for the Centers for Disease Control and Prevention. Did he mention to you that we might call?

If NO – Are you interested in hearing about the study, and if you might qualify?

If No – That’s fine. Thank you for your time. Have a good day. (Hang up)

If Yes – OK, great! Let me tell you a little bit about the study.

If YES – OK, great. Let me tell you a little bit about the study.

The purpose of this research project is to get your opinion about treatment, prevention, and care of those living with HIV and to better understand the role of partners in HIV medication and treatment.

It is an in-person in-depth interview and should take about an hour, depending on your answers. It will be audio recorded so researchers can review the information—no names will be used. At the end of the interview you will receive $40 [in cash /in the form of a gift card].

All information will be kept private. Would you be interested in answering a few questions to see if you are eligible to participate in the study?

[ ]YES- Go to Section 2

[ ]NO- Thank you for your time.

iQual Insight Screener SDP SDPHID

Section 1 IF R CALLS and it is determined that he may be a Partner of a PLWH continue with Q1:

Information about the caller.

1. IF NOT CLEAR ABOVE: Ask caller: Who referred you to this study? DO NOT WRITE DOWN NAME, DETERMINE IF PLWH.

2. IF NOT ANSWERED ABOVE Ask caller:

Why do you think you qualify for the study?”

3. Tell them:

I need to ask you a few questions to determine if you are eligible for this project.

START HERE IF RECRUITER CALLS R OR CONTINUE FROM SECTION 1 IF R CALLED IN:

Section 2 Determine eligibility as SDP

4. How long have you been involved with your partner?

Section 2 Determine eligibility as R

5. Are you over 18 years of age?” Yes [ ] No [ ]

6. “Do you consider yourself to be male, female, or transgender?[CHECK ONLY ONE.]

a) Male

b) Female

c) Transgender

d) REFUSED TO ANSWER

e) DON’T KNOW

7. Have you tested positive for HIV? [ ] Yes [ ] No

iQual Insight Screener SDP SDPHID

Section 3 ELIGIBILITY CHECK

INTERVIEWER INSTRUCTION TO CHECK ELIGIBILITY:

 DURING CONVERSATION ASSESS THEIR ABILITY TO SPEAK ENGLISH OR SPANISH (SHOULD BE ABLE TO CONVERSE WITHOUT DIFFICULTY).

 IF YOU DETERMINE ENGLISH AND SPANISH VERY POOR—NOT ELIGIBLE.

 IF THEY SOUND BIZARRE ON THE PHONE (DISORGANIZED THOUGHTS, CONFRONTATIONAL, ANGRY, ETC)—NOT ELIGIBLE.

 R IS MALE,

 HIV-DISCORDANT,

 OVER 18

 R IS A LONG TERM ( 6 MONTHS PLUS) PARTNER OF AN IQUAL PARTICIPANT.

INTERVIEWER FILL : [ ] ELIGIBLE [ ] NOT ELIGIBLE

IF ELIGIBLE: WRITE NAME AND NUMBER ON AN SDP CONTACT FORM. CONTACT FORM SHOULD BE KEPT SEPARATE FROM SCREENER. IT AND SCREENER ARE BOTH PRIVATE INFORMATION. PII INFORMATION SHOULD NOT BE KEPT IN ELECTRONIC FORMAT.

Tell them more:

 The purpose of this research project is to get your opinion about treatment, prevention, and care of those living with HIV and to better understand the role of partners in HIV medication and treatment.

• Funding for this study is provided by the Centers for Disease Control and Prevention (CDC).

 We expect to enroll about 100 people in 5 cities across the country.

 It should take about an hour, depending on your answers.

 It will be audio recorded so researchers can review the information—no names will be used.

 You will receive $40[ in cash/ in the form of a gift card].

 There will be a questionnaire to fill out about your personal background.

 All information will be kept private.

 Your care or services from any clinic or center will not be affected in any way by your decision of whether or not to participate in the study.