Form 0920-1091 D2C Client Screener

Form

OMB No: 0920-1091

Exp. Date: 12/31/2018

The Data to Care (D2C) Public Health Strategy: Successes, Challenges, and Lessons Learned in Identifying, Linking, and Reengaging Persons Diagnosed with HIV to Medical Care

Attachment 3a: D2C Client Screener

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)

PLWH PID:___________

Date: _______________

Recruiter: ___________

Location: ___________

D2C PLWH Screener - Version 2.0

Administration: Potential participants will call a toll-free phone number listed on the recruitment flyer. This screener will be administered over the phone by an RSS staff person.

Narrative to read to Potential Participant:

• Let me tell you a little about the study. The purpose of this research is to learn more about your experience getting into or staying in HIV care.

• All information will be kept private.

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

The study consists of a face-to-face, confidential interview that should take about an hour of your time at a place convenient to you.

I have a few questions for you to make sure you qualify for the study.

1. a. Where did you learn about the study?_______________________

b. Who told you about the study? Can you tell us their name? ________________

c. Were you given a code to provide to us? If so, what is it? _______________

2. How old are you? _________ (eligibility criteria)

1. 0-17 (STOP, Not Eligible)

2. 18+

Thank you, that’s all the questions I have. I just need to collect some contact information now so we can reach you later to schedule your interview.

Continue to contact sheet then return here after call is finished to confirm eligibility

ELIGIBLE IF:

(All must be checked)

• 18 or older

• Can speak English

• Able to complete In Depth Interview (does not sound/appear to be under the influence of drugs or alcohol/disoriented/confrontational/has much trouble with screener questions/combative)

• (Re)engaged in HIV care through a local data to care program (Matching list provided by hd)

FAQs about the study:

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

• We expect to enroll about 60 persons living with HIV and 30 Data to Care program personnel in 3 cities across the country.

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

• The interview will be audio recorded so researchers can review the information following the interview —no identifiable information will be shared.

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