Demographic Screener

Form Approved

OMB No. 0920-0840

Expiration Date 02/29/2016

“Evaluating a HIV/AIDS Focused Video Game for Young People”

Attachment 3a. Participant Demographic Screener

Public reporting burden of this collection of information is estimated to average 1 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)

Participant Eligibility Form

Study staff will read the following: Thank you for our interest in the study we would like to ask you a few questions to see if you are eligible to participate

What is your name? ______________________________________

1. How old are you? _____ years

2. What grade are you in currently _____

3. Do you live in metro Atlanta? _____ Yes

_____ No

4. What sex are you? _____ male _____ female _____ transgender

5. Are you Hispanic or Latino? _____ yes _____ no

6. What is your race? (Check all that apply) _____ American Indian or Alaska Native

_____ Asian

_____ Black or African American

_____ Multiracial

_____ Native Hawaiian or Other Pacific Islander

_____ White

_____ Other; please describe _________________

IF NOT ELIGIBLE, THANK YOU FOR YOUR TIME. You are ineligible because you are not 11-24 years old or do not live in metro Atlanta or both. There may be other research projects you can participate in the future.

IF ELIGIBLE,

Please provide us with your contact information so that we can schedule you for the study

Name ____________________________________

Contact Phone Number #1 ____________________________________

Contact Phone Number #2 ____________________________________

ID # ____________

Recruitment Site ____________________________________