Form 1 Survey Screener

Appendix E Survey Screener

Script

Hi, my name is _________ and I am the coordinator for a study on the use of technology to improve the health of young people living with HIV. The study is being conducted by RTI International, a not-for profit research organization, with funding from the U.S. Department of Health and Human Services, Health Resources and Services Administration.

The purpose of the study is to explore whether text messages about a variety of topics improve the health of young people living with HIV. If you are interested and eligible to participate, you will be enrolled in the 9-month study. During the 9-month period, participants will be asked to complete four web-based surveys and may receive daily text messages. Participants will receive $25 at enrollment when they complete one survey and $25 for completing each of three follow-up surveys for a maximum compensation amount of $100. Participants may also be asked to participate in a telephone interview. If they are selected and agree to participate in a telephone interview, they will receive an additional $25.

Do you have any questions about the study?

IF YES, NOTE QUESTIONS

Before continuing, I have to ask you a few questions to see if you are eligible to participate. Some of the questions I am going to ask you are of a sensitive nature, so I would like to make sure that you are in a private location before we begin. May I ask you the questions now?

IF NO, THANK PATIENT FOR THEIR TIME AND END

IF YES, ASK: Are you in a private location?

IF YES, CONTINUE TO SCREENING QUESTIONS

IF NO, ASK PARTICIPANT IF HE/SHE CAN MOVE TO A PRIVATE LOCATION.

IF YES, CONTINUE TO SCREENING QUESTIONS

IF NO, SCHEDULE A TIME TO COMPLETE THE SCREENER WHEN THE PARTICIPANT CAN DO SO IN PRIVATE.

Screening Questions

1. What is your current age? __________

 Under age 15  Terminate

 Age 15-24

 Age 25 or older  Terminate

2. Please indicate your ethnic background.

 Hispanic or Latino

 Not Hispanic or Latino

3. Please indicate your race.

 White/Caucasian

 Black or African American

American Indian or Alaska Native

 Native Hawaiian or Other Pacific Islander

 Asian

4. Which of the following best describes your gender?

Male

Female

Trans-male

Trans-female

5. Have you ever been sexually active with another person?

Yes

No

6. Which of the following best describes your sexual identity?

Homosexual/Gay/Same gender loving/Queer

Straight/Heterosexual

Bisexual/two-spirited

Other_______________________

7. What is your HIV status?

Positive……………………………………………………………..

Negative……………………………………………………………. Terminate

Unknown……………………………………………………………Terminate

8. Do you have a working cell phone with text messaging capability?

 Yes

 No Terminate

9. Do you own this cell phone?

 Yes

 No Terminate

10. Would you be willing to receive and read text messages during the 9-month study period?

 Yes

 No Terminate

11. Would you be willing to allow the study coordinator to access your medical records every three months to record your most recent CD4 count and viral load, assess appointment attendance, and the medications you are taking to treat HIV?

 Yes

 No Terminate

Termination Script

I’m sorry but you are not eligible to participate in this study. Thank you for your time and interest.

If Eligible

Great, you are eligible to participate in this study. I would like to set up a time to meet with you in person so that we can review the informed assent [aged 15-17]/consent [age 18+] documentation together to make sure you understand the potential risks associated with this study. We will also discuss with you the types of messages you might receive during the study. Then we will ask you to complete an online survey using a private computer at the clinic. The initial meeting may take up to 2 hours.

Can we schedule our initial meeting now?

Great!

[Onsite study coordinator to schedule appointment to coincide with next routine primary care visit to the extent possible.]

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