Eligibility Screener

Attachment 2a

Eligibility Screener (English)

Form Approved:

OMB No. 0920-0770

Expiration Date: XX/XX/XXXX

National HIV Behavioral Surveillance System: Eligibility Screener

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, Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0770). Do not send the completed form to this address.

National HIV Behavioral Surveillance System: Eligibility Screener

AUTO1. NHBS Round ___ ___ AUTO2. NHBS Cycle ____ (1=MSM; 2=IDU; 3=HET)

AUTO3 Date of Interview: __ __/ __ __ / __ __ __ __ AUTO4. Time Begin __ __:__ __  1AM  2PM

^{(M M / D D / Y Y Y Y )}

AUTO5. Version ______________________________________

Interviewer Entered Information

INT1. Interviewer ID __ __

INT2. Enter City __ __

INT3. Survey ID ___ ___ ___ ___

If the length of Survey ID is 4 digits and Cycle=1 skip to INT4;

If the Length of Survey ID is 4 digits and Cycle=2 or 3 skip to INT9.

CONF1. Interviewer: The survey ID that you entered was [INT3]. Is this correct?

No………………………………………………  0 Loop back to INT3

Yes……………………………………………...  1

If NHBS-IDU or NHBS-HET (CYCLE=2 or 3), skip to INT9.

INT4. Venue Code ___ ___ ___ ___

INT5. Event Number ___ ___ ___ ___

INT6. Interviewer: Is this interview a “Post Event Appointment”?

No……………………………………  0 Skip to Say Box before ES1

Yes……………………………………………...  1

If INT4 is equal to 0, the skip to Say box before ES1.

P ost Event Appointment

INT7. Enter the field site ID for the location of the interview: ___ ___ ___ ___

INT8. Enter the date of the recruitment event: ___ ___ / ___ ___/ ___ ___ ___ ___

^{M M / D D / Y Y Y Y}

If NHBS-MSM (CYCLE=) 1, skip to Say Box before ES1.

INT9. Field Site ID ___ ___

CONF2. Interviewer: The field site ID that you entered was [Response to INT9]. Is this correct?

No……….……………….…………..  0 Loop back to INT9

Yes………………………….…….........  1

INT10. Interviewer: Is participant a seed?

No……….……………….…………..  0

Yes………………………….…….........  1

FOR ALL NHBS CYCLES

SAY: I’d like to thank you again for your interest in this health survey. Remember that all information you give me will be kept private and I will not ask for your name. First, I will ask you a few questions about yourself and then the computer will determine if you have been selected to participate in the health survey.

Eligibility Screener Questions

ES1. What is your date of birth?

__ __/ __ __ / __ __ __ __

[Refused = 77/7777, Don't know = 99/9999] ^{(M M / D D / Y Y Y Y )}

So, you are [insert calculated age] years old. Is that correct?

No……….……………….………….. 0 Loop back to ES1

Yes………………………….……...... 1

If Respondent is <18 years old, skip to End1

ES2. During 20xx, did you already complete at least part of the health survey that [Insert Project Name] is conducting? It could have been here or at another location.

No………………….……………………………  0

Yes……………………………………………...  1

Known previous participant…………………...  2

Refused to answer………………………………  7

Don't know……………..……………………...  9

ES3. Do you consider yourself to be Hispanic or Latino/a? [Interviewer: If necessary, say “Just tell me Yes or No.”]

No………………….……………………………  0

Yes……………………………………………...  1

Refused to answer………………………………  7

Don't know……………..……………………...  9

If ES3 in (0, 7, 9), skip to ES4.

ES3a. What best describes your Hispanic or Latino ancestry?

[READ CHOICES. CHECK ALL that apply.]

Mexican…………….…..………………………  1

Puerto Rican………..…………………………...  2

Cuban…………...…………………..…………..  3

Dominican……...…………………..…………..  4

Some other ancestry (Specify)………………..... 5

Refused to answer………....……………………  7

Don't know………………………..…………….  9

ES4. [GIVE RESPONDENT FLASHCARD A.] Which racial group or groups do you consider yourself to be in? You may choose more than one option. [READ CHOICES. CHECK ALL THAT APPLY.]

American Indian or Alaska Native……………  1

Asian ..……………………..……………….......  2

Black or African American ……………..……..  3

Native Hawaiian or Other Pacific Islander…….  4

White ……………..…………………………….  5

Refused to answer………....……………………  7

Does not apply ………....……………………  8

Don't know………………………..…………….  9

ES5. What county do you currently live in?_________________________________________

(List of eligible counties on computer)

If “Other” county chosen, specify, then skip to Logic check before ES6.

ES5a. How long have you been living in [project area]? (Interviewer: If response is in months, enter 0 below and then enter the number of months in the next screen.)

Years __ __ [Refused = 777, Don't know = 999]

If ES5a= 1-100, 777, or 999, skip to Logic Check before ES6

ES5b. Number of months: __ __

range of values= 1-11 [Refused = 77, Don't know = 99]

For NHBS-MSM, skip to ES8

For NHBS-IDU, skip to ES9

For NHBS-HET, ask ES6 - ES7a, then skip to ES9

ES6. What zip code do you live in?

[Refused = 77777, Don't know = 99999] __ __ __ __ __

ES7. SHOW RESPONDENT THE MAP. Please take a look at this map. Can you point to the area where you live?

Interviewer: Enter 6-digit census tract #_____________

(Refused= 777777, Don't know= 999999)

ES7a. IF RESPONDENT IS A SEED (INT10=1)

Interviewer: Does participant live in a High Risk Area?

No ………………………………………………… 0

Yes ………………………………………………... 1

Skip to ES9

FOR NHBS-MSM

ES8. What was your sex at birth? [CHECK only ONE]

Male…...……………………………………….  1

Female…....…....……………………………….  2

Intersex/ambiguous………....………………….  3

Refused to answer………....………………  7

Don't know……………..……………………..  9

FOR ALL NHBS CYCLES

ES9. Do you consider yourself to be male, female, or transgender? [CHECK only ONE]

Male…...……………………………………….  1

Female…....…....……………………………….  2

Transgender………………....………………….  3

Refused to answer………....………………  7

Don't know……………..……………………..  9

If NHBS-IDU skip to ES10. If NHBS-HET, skip to Logic check before ES17.

NHBS-MSM behavioral eligibility questions

ES9a. Have you ever had vaginal or anal sex with a woman?

No………………….……………………………  0

Yes……………………………………………...  1

Refused to answer………………………………  7

Don't know……………..…………………….....  9

ES9b. Have you ever had oral or anal sex with a man?

No………………….……………………………  0

Yes……………………………………………...  1

Refused to answer………………………………  7

Don't know……………..…………………….....  9

FOR NHBS-MSM, skip to SAY Box before ES18

FOR NHBS-IDU, ask ES10 - ES17b, then skip to SAY Box before ES18

FOR NHBS-HET, skip to Logic Check before ES17

NHBS-IDU behavioral eligibility screener questions

ES10. Have you ever in your life shot up or injected any drugs other than those prescribed for you? By shooting up, I mean anytime you might have used drugs with a needle, either by mainlining, skin popping, or muscling.

No………………….……………………………  0 Skip to SAY box before ES18

Yes……………………………………………...  1

Refused to answer………………………………  7

Don't know……………..…………………….....  9 Skip to SAY box before ES18

ES11. When was the last time you injected any drug? That is, how many days or months or years ago did you last inject? [Interviewer: Enter the number below. If today, enter 0]

Number __ ___ ___

[Refused = 777, Don't know = 999]

If ES11 in (777, 999), skip to ES12.

ES11a. Interviewer: Was this days or months or years? [If today, enter “days”]

Days…………………1

Months.…………….. 2

Years……………….. 3

Refuse to answer….…7

Don’t know……….…9

ES12. Which drug do you inject most often? [READ CHOICES. CHECK ONLY ONE]

Speedball – Heroin and cocaine together ……. 1

Heroin, by itself………………… …………….. 2

Cocaine, by itself……………………………… 3

Crack………………………………………….. 4

Crystal, meth, tina, crank, ice……………………... 5

Something else (Specify________________). 6

Refused to answer………....…………………  7

Don't know………………………..…………  9

ES13. Where on your body do you usually inject? [CHECK ALL THAT APPLY]

[Interviewer: Have participant show ALL injection areas on body. Check for physical signs of injection]

Fresh track marks……………………………… 1

Needle-sized scabs…………………………….. 2

Abscesses……………………………..………. 3

Old track marks or scars...…………………….. 4

Injects in covered area ...………………………. 5

No physical signs...…………………………….. 6

Respondent refused to show…..……………….. 7

If participant has no visible physical signs of current injection, ask ES14-ES16. Otherwise, go to SAY Box before ES18.

ES14. Step-by-step, tell me how you prepare your drugs.

INTERVIEWER:

Description could include:

Mix drugs with water or lemon juice/vinegar

Use cooker /Heat drugs

Use filter

Description OK………………………………… 1

Description Not OK……………………………. 2

ES15. Step-by-step, tell me how you inject your drugs.

INTERVIEWER:

Description could include:

Tie off and find vein (IVDU)

Clean injection site

Register (IVDU)

Description OK……………………………… 1

Description Not OK………………………….. 2

ES16. What type of syringe do you usually inject with?

INTERVIEWER:

Description could include:

Syringe size (in cc’s or units)

Needle size (gauge, length)

Cap (color, number)

(Can also ask where they usually get syringes, what they do with them after injecting, and how they know if they are new or used)

Description OK……………………………… 1

Description Not OK………………………….. 2

If NHBS-IDU, skip to SAY Box before ES18

NHBS-HET behavioral eligibility questions

SAY: The next questions are about having sex. Please remember your answers will be kept private.

IF ES9 is not 1 (male) or 2 (female), then skip to ES17c.

ES17. Have you had sex with a [insert “man” if respondent is female; insert “woman” if respondent is male] in the past 12 months?

No………………………………………………  0

Yes……………………………………………...  1

Refused to answer………....…………………  7

Don't know………………………..…………  9

If ES17 is not 1, skip to SAY box before ES18.

ES17a. Did you have vaginal sex? By vaginal sex, I mean [insert “he put his penis in your vagina” if respondent is female; insert “you put your penis in her vagina” if respondent is male].

No………………………………………………  0

Yes……………………………………………...  1

Refused to answer………....…………………  7

Don't know………………………..…………  9

If ES17a = 1, skip to SAY box before ES18.

ES17b. Did you have anal sex? By anal sex, I mean [insert “he put his penis in your anus (butt)” if respondent is female; insert “you put your penis in her anus (butt)” if respondent is male]

No………………………………………………  0

Yes……………………………………………...  1

Refused to answer………....…………………  7

Don't know………………………..…………  9

If ES17b = 1, skip to SAY box before ES18.

CONF3. Ask the following if ES17=1 AND ES17a=0 AND ES17b=0):

“So, in the last 12 months, you only had oral sex with a [insert “man” if respondent is female; insert “woman” if respondent is male]? Is that correct?

If NOT correct, go back to ES17a.

If CORRECT, go to SAY box before ES18.

ES17c. Have you had sex in the past 12 months?

No………………………………………………  0

Yes……………………………………………...  1

Refused to answer………....…………………  7

Don't know………………………..…………  9

SAY: We’ve finished the first series of questions. Now the computer will determine whether you’ve been selected to participate in the survey.

NHBS Round 3 Questionnaire, v. 13 – Clean 8

December 5, 2011