Form Approved
OMB No. 0920-0920
Development of Messages for the Act Against AIDS National Testing Campaign
ATTACHMENT 3 Web-based Screener
Public reporting burden of this collection of information is estimated to average 2 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 (0920-0920)
We are asking people to be in a research study that will help us learn more about what people think about HIV prevention and testing messages and advertisements. RTI International, a research company in North Carolina is conducting the study. The Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia is funding the research.
To see if you are a good match for this study, we will need to ask you some personal questions. Some of the questions will be about your sexual orientation, recent sexual activity, and your HIV status, if you know it. It is your choice to answer the questions. Your answers will be kept private to the extent allowed by law. You can refuse to answer any question or stop at any time.
May we ask you the questions to see if you are a good match for this study?
1 Yes [CONTINUE]
2 No [IMMEDIATE TERMINATE]
Background Information
S1. How old are you?
Age__________ [INELIGIBLE IF UNDER 18 OR OVER 64]
8 Don’t know [INELIGIBLE]
9 Prefer not to answer [INELIGIBLE]
S2. What was your sex at birth?
1 Male
2 Female
2 Intersex/ambiguous
8 Don’t know [INELIGIBLE]
9 Prefer not to answer [INELIGIBLE]
S3. Do you consider yourself to be male, female, or transgender? (check only one)
1 Male
2 Female
3 Transgender
8 Don’t know [INELIGIBLE]
9 Prefer not to answer [INELIGIBLE]
S4. Which do you consider yourself to be?
1 Gay or homosexual
2 Bisexual
3 Straight or heterosexual
4 Other [Specify: ]
9 Prefer not to answer [INELIGIBLE]
S5. Are you of Hispanic or Latino origin?
1 Yes
2 No
9 Prefer not to answer [INELIGIBLE]
S6. Please indicate your race. Are you? You may select one or more races.
1 White
2 Black or African American
3 Asian
4 Native Hawaiian or Other Pacific Islander
5 American Indian or Alaska Native
8 Don’t know [INELIGIBLE]
9 Prefer not to answer [INELIGIBLE]
S7. Have you ever been tested for HIV? An HIV test checks whether someone has the virus that causes AIDS.
1 Yes
2 No [SKIP TO S10]
9 Prefer not to answer [INELIGIBLE]
S8. In the past 2 years, that is, since [insert calculated month and year], how many times have you been tested for HIV?
0 0
1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9 or more
10 Prefer not to answer
S9. The next question is about the result of your HIV test. What was the result of your most recent HIV test?
1 I tested positive for HIV. [INELIGIBLE]
2 I tested negative for HIV.
3 My results were unclear.
8 I never got my results/Don’t know.
9 Prefer not to answer [INELIGIBLE]
S10. Have you had vaginal sex (penis in the vagina), anal sex (penis in the butt), or oral sex (mouth on the penis) in the past 12 months?
1 Yes
2 No [INELIGIBLE]
9 Prefer not to answer [INELIGIBLE]
If eligible – Invitation:
Thank you for answering all of the questions. You are eligible to take part in the survey.
Would you like to participate in this survey?
1 Yes [CONTINUE]
2 No [INELIGIBLE]
If ineligible – Closing:
Thank you for answering all of the questions. You are not eligible to be in this study because you did not meet our eligibility criteria. These reasons were decided on earlier by the researchers. We value your interest in this research study. Thank you for being willing to help us.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Coomes, Curtis |
| File Modified | 0000-00-00 |
| File Created | 2021-01-25 |