Sample Study Screener

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/XXXX

Attachment 3a Sample Study Screener

Using Rapid Assessment Methods to Understand Issues in

HIV Prevention, Care and Treatment in the United States

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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

Date: ____________

Eligible____________

Partner Eligible____________

Recruiter Initials____________

1. Ask caller about their eligibility

1. Are you older than 18?

(if Younger than 18, stop here. Move to skip to Contact Form - NOT eligible.)

1. How old are you?

   1. 18 – 25 years old

   2. 26 – 35 years old

   3. 36 years and over

2. Do you consider yourself to be male, female, or transgender?

1. ____ Male

2. ____ Female

3. ____ Transgender

4. ____ Other: _________________

(IF female or Other, skip to Contact Form - NOT eligible.)

3. Are you Hispanic, Latino/a, or Spanish origin? (Interviewer, check one)

[ ] No
[ ] Yes

[ ] Refused to answer

4. What is your race? You may choose more than one category . [READ CHOICES. CHECK ALL THAT APPLY.]

1. ____American Indian or Alaska Native

2. ____Asian

3. ____ Black or African American

4. ____Native Hawaiian or Other Pacific Islander

5. ____White

6. ____Refused to answer

(If response is not AA or Hispanic, Skip to Contact Form - NOT eligible.)

5. Have you tested positive for HIV?
[ ] No
[ ] Yes

[ ] Refused to answer

If No, or refused to answer skip to Contact Form - NOT eligible.

6. What month and year did you first test positive for HIV? Tell me when you got your result, not when you got your test.

__________Month

__________Year

7. During the past 6 months have you had sex with a man?

1. Yes

2. No

3. DK

4. Refused to answer

IF no, skip to Contact Form - NOT eligible.

continue screening for targeted characteristics.

Determine their treatment cohort:

8. Are you currently taking antiretroviral medicines (HIV meds)?

Yes [ ] IF COHORT FILLED SKIP TO CONTACT FORM; OTHERWISE SKIP TO (PARTNER)

No [ ] IF COHORT FILLED SKIP TO CONTACT FORM; OTHERWISE CONTINUE BELOW

9. Which of the following best describes your treatment status as of today?
(Interviewer, READ CHOICES OUT LOUD, then check one)

1. ____ Started HIV medicines, but stopped (no longer taking them)

2. ____ Have never taken HIV medicines

3. ____ Refuse to answer

4. ____ Don’t know/Don’t Remember
   
   
   

Tell them more about the study:

• The purpose of this research project is to get your opinion about treatment, prevention, and care of those living with HIV and what motivates or discourages patients in taking their HIV medications.

• Funding for this study is provided by the Centers for Disease Control and Prevention (CDC).

• We expect to enroll about 100 people in 5 cities across the country.

• It should take about an hour, depending on your answers.

• It will be tape recorded so researchers can review the information—no names will be used.

• You will receive a [gift card of $40/$40 cash.]

• All information will be kept private.

• Your care or services from any clinic or center will not be affected in any way by your decision of whether or not to participate in the study.

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