Att 5 Behavioral Survey Instruction Card

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

HIV Outpatient Study (HOPS)

Attachment 5

Behavioral Survey Instruction Card

Each HOPS study site provides a similar information card for study participants to complete the

TACASI or web-based CASI assessment.

Patient Information Card

My ID number is : ___ ___ ___ ___

Please dial 1-888-270-7809 to begin.

Responses:

1=yes

2= no

* = repeat question

# = skip to next question

To access the internet version of the survey go to:

http://hops.brightoutcome.com

Please use your ID number for both the Username and Password