Form Approved
OMB No. 0920-0572
Exp. Date XX/XX/XXXX
Act Against AIDS – MSM Audiences
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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0572).
Hello, my name is _______________ and I’m from (name of company). We are calling on behalf of RTI International, a non-profit organization, and the Centers for Disease Control and Prevention.
We are not selling any product. We are calling to invite men in your area to join in interviews as part of a project about HIV testing and prevention. Your opinions are important to us and will contribute to the CDC’s fight against HIV/AIDS.
If you are eligible and choose to participate in the interview, we will give you $40 as a token of appreciation. To see if you are eligible for this project, we need to ask you some personal questions. There will be some explicit questions about your sexual behavior and HIV. It is your choice to answer these questions. Your answers will be kept private to the extent allowable by law. You can refuse to answer a question or stop at any time.
If you are eligible and choose to participate in the project, we will ask for your contact information so that we can send you a reminder letter/email and call to remind you about the interview. All of your contact information will be destroyed immediately after the interview and you will not be contacted again. All of the comments you make during the interview will be kept private to the extent allowable by law. Any forms related to the project that have your name or information that could identify you will be kept in a locked file cabinet or on a password protected computer. These forms will be destroyed at the end of the project.
If you are not eligible and/or choose not to participate in this project, all responses you give me today will be destroyed upon the end of our conversation and you will not be contacted again.
My questions will only take a few minutes. May I ask you the questions now?
Yes..................1 [Continue]
No....................2 [End]
Procedures for Recording and Limiting Information
Only record information for the questions in the screener. If any informant reveals additional personal information, thank them for being helpful, but guide them back to the screener questions- “That is interesting to learn, but can I now ask you about. . .”
Gender
Male
Female INELIGIBLE: Read script for ineligibles
In which of the following categories does your age fall:
Under 18 years of age INELIGIBLE: Read script for ineligibles
18-24 years of age
25-34 years of age
35-44 years of age
45-54 years of age
55-64 years of age
65-74 years of age INELIGIBLE: Read script for ineligibles
75 years of age or older INELIGIBLE: Read script for ineligibles
Please indicate your race or ethnic background. Are you?
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Race: SELECT ONE OR MORE.
White/Caucasian
Black or African-American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Asian
Now I am going to ask you a few sensitive questions about HIV/AIDS and your sexual activity. All of your answers will be kept private to the extent allowable by law.
Now I am going to ask you to describe your sexual identity. Would you describe yourself as:
Homosexual or “gay” or same gender loving
Bisexual or two spirited
Heterosexual or “straight” INELIGIBLE: Read script for ineligibles
Other, specify:_____________ INELIGIBLE: Read script for ineligibles
Don’t know INELIGIBLE: Read script for ineligibles
Decline to answer INELIGIBLE: Read script for ineligibles
Within the past 6 months, who have you primarily had sex with?
A male
A female
Haven’t had sex in the past 6 months
Refused
What is your current relationship status? Are you…?
Single
Married to a man
Married to a woman
In a relationship with a man
In a relationship with a woman
Divorced or widowed
Refused
Within the past 6 months, have you had unprotected sex? By “unprotected sex” we mean having sex without a condom.
Yes
No
Refused
Within the past 6 months, have you had sex with more than one partner?
Yes
No
Have you ever had an HIV test?
Yes
No [Skip to 3a]
When was the last time you had an HIV test?
_________________(record date)
What was the result of your last HIV test?
Positive
Negative
Don’t know
Thank you, I just have a couple more questions.
What is the highest level of education you have completed?
Grade school
Less than high school graduate/some high school
High school graduate or completed GED
Some college or technical school
Received four-year college degree
Some post graduate studies
Received advanced degree
Other: ____________
Which of the following categories best describes your total, annual household income?
Under $20,000/year
$20,001 – $30,000/year
$30,001 – $40,000/year
$40,001 – $50,000/year
$50,001 – $60,000/year
$60,001 – $80,000/year
$80,001 – $100,000/year
Over $100,000/year
IF INDIVIDUAL IS BETWEEN 18 AND 64 YEARS OF AGE AND HOMOSEXUAL OR BISEXUAL, READ INVITATION FOR ELIGIBLE PARTICIPANTS
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | uyy6 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-25 |