Sscreener

Form Approved

OMB No. 0920-1027

Expiration Date: 08/31/2017

Title of Project: Formative Study to Inform HIV Screening and PrEP Resources for Health Care Providers

Attachment A: Screener

Public reporting burden of this collection of information is estimated to average 10 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 (0920-1027)

Hello, my name is _______________ and I’m from (name of company). We are calling on behalf of RTI International, a non-profit research organization, and the Centers for Disease Control and Prevention. We are not selling or promoting any product. We are calling to recruit health care providers to provide feedback on the development of materials about HIV testing and prevention.

The purpose of the study is to learn health care providers’ thoughts on a communication campaign and educational materials being developed for health care providers and involves participating in an interview. To see if you are eligible for this study, I need to ask you some questions. If you are eligible and choose to be in the study, all of your comments will be kept private. In appreciation for your participation, you will receive $250 as a token of appreciation.

My questions will only take a few minutes. May I proceed?

1. First, does any member of your household or immediate family work for or receive any compensation from:

A market research company _____

An advertising agency or public relations firm _____

The media (TV/radio/newspapers/magazines) _____

The CDC _____

MAX. 1 OR 2  A pharmaceutical company _____

[IF “YES” TO ANY  GET SPECIFICS AND HOLD.

RECRUITMENT FACILITY SHALL CONTACT RTI TO DETERMINE WHETHER TO RECRUIT THE INDIVIDUAL]

2. Have you attended a focus group discussion or individual interview in the last six months about HIV? By interview we mean an informal, one-on-one discussion and by focus group we mean an informal, round-table discussion, conducted by a facilitator, in which you were asked your professional opinions regarding something related to HIV?

YES		 TERMINATE
NO		 CONTINUE

2. Are you licensed to practice medicine or nursing in the US?

NO		 TERMINATE
YES		 CONTINUE

[NOTE: MAXIMUM OF 25% OF RESPONDENTS SHOULD BE NPs OR PAs]

2. How many years have you been practicing medicine or nursing? ______________

3. Are you a?

Family Medicine Physician		 GO TO Q5A
Internal Medicine Physician		 GO TO Q5A
Nurse Practitioner		 CONTINUE TO Q6
Physician Assistant		 CONTINUE TO Q6
Other		 TERMINATE

ASK FAMILY PRACTICE AND INTERNAL MEDICINE PHYSICIANS ONLY

5A. Do you have a sub-specialty?

Yes _____  Go to Q5B

No _____  CLASSIFY AS PCP AND CONTINUE TO Q6

5B. What is your sub specialty? _____________________________________

[Check all that apply]

• Adolescent medicine

• Allergy and immunology

• Cardiology

• Endocrinology

• Gastroenterology

• Geriatrics

• Hematology

• HIV Medicine

• Infectious Disease

• Nephrology

• Oncology

• Pulmonology

• Rheumatology

• Sports medicine

• Other: ___________________

2. In what setting do you see patients? (RECORD ALL THAT APPLY)

Private practice (By private practice, we mean a private physician’s office or group practice.)
Community Hospital
HMO (such as Kaiser)
Academic/University-affiliated hospital
Community Clinic/Health Center
Government/Military Facility
Other

7. Does your clinic receive Ryan White funding?

NO		 CONTINUE
YES		 CONTINUE

8. Do you accept any of the following payment options? (RECORD ALL THAT APPLY)

MEDICAID
MEDICARE

8. Had you heard of the HIV Screening. Standard Care. (HSSC) campaign before we contacted you about this study?

NO		 SKIP TO QUESTION 10.
YES		 CONTINUE TO QUESTION 9A.

9a. Are you or had you been directly involved in the campaign’s development or publicity?

YES		TERMINATE
NO		 CONTINUE – SPECIFY – How have you heard of the HSSC Campaign previously? ____________________________

8. Do you routinely screen all of your patients ages 13-64 years for HIV?

YES
NO

[NOTE: TARGET IS MAXIMUM OF 25% OF RESPONDENTS SHOULD ANSWER “Yes”]

8. Please tell me your age._____________

[Terminate if less than 26, greater than 75]

[NOTE: AIM FOR APPROXIMATELY 25% OF RESPONDENTS ≤39 YEARS AND APPROXIMATELY 10% OF RESPONDENTS ≥ 60 YEARS]

8. Gender

Male
Female

[NOTE: STRIVE FOR EQUAL PROPORTIONS OF MEN AND WOMEN]

How would you describe your racial/ethnic background? [READ LIST for Q14Q14. IF NECESSARY]

8. Are you Hispanic or Latino/a?

YES
NO
Refused

8. What is your race? (One or more categories may be selected)

White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Refused

[NOTE: AIM FOR APPROXIMATELY 50% OF RESPONDENTS TO BE PROVIDERS OF COLOR (i.e., NON-WHITE)]

Invitation:

Thank you for answering all of my questions. As I mentioned earlier, we are conducting a study on behalf of the CDC regarding a communications campaign under development for providers and would like to hear your professional views. In order to hear them first-hand, we would like to invite you to take part in an informal, personal interview. The interviews are being scheduled on [DAYS/DATE TBD]. The discussion will last about 1 hour. No one will attempt to sell you anything. To help repay you for your time, effort, and travel expenses, you will receive $250 at the time of the interview. The interviews will be audio-recorded, and CDC staff may observe the interview. Can we schedule your attendance?

Closing for Ineligible Participants:

Thank you for answering my questions. At this time you are not eligible to be in this study. We value your interest in this study. Thank you for being willing to help us.