Att 6 Sample Screening Tool

Form Approved

OMB No. 0920-0840

Exp. Date 02/29/2016

Generic Clearance

Formative Research and Tool Development

Attachment 6

Sample Screening Interview

Public reporting burden of this collection of information is estimated to average 10 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 (0920-0840)

[INSERT PHASE NAME]

Study Screener

Introduction

Thanks for your willingness to complete this online survey. We are asking [INSERT TARGET GROUP] to take part in a research study about [INSERT TOPIC].

This survey is sponsored/funded by the Centers for Disease Control and Prevention (CDC). The purpose of the research is to [INSERT PURPOSE].

To see if you are eligible for this study, I need to ask you some questions. If you are eligible and choose to be in the study, all of your answers will be kept private.

Background Information

How old are you?

Age__________

1. Don’t know

2. Refuse to answer

What is your gender?

1. Male

2. Female

3. Other [Specify: ]

4. Don’t know

5. Refuse to answer

Are you of Hispanic or Latino origin?

1. Yes

2. No

3. Don’t know

4. Refuse to answer

Which of the following best describes your race?

1. African American or Black

2. American Indian or Alaska Native

3. Asian

4. Native Hawaiian or Other Pacific Islander

5. White

6. Check all that apply

7. Don’t know

8. Refuse to answer

What is the highest grade or year of school you finished?

1. Never attended school or only attended kindergarten

2. Grades 1 through 8 (elementary)

3. Some high school

4. High school graduate (includes GED)

5. Some college or technical school

6. College or technical school graduate

7. Don’t know

8. Refuse to answer

Which best describes your total personal income during the past year?

1. Less than $20,000

2. $20,000-$39,999

3. $40,000-$59,999

4. $60,000-$69,000

5. $70,000-$79,000

6. $80,000 or above

7. Don’t know

8. Refuse to answer

Are you currently a college student?

1. Yes

2. No

3. Don’t know

4. Refuse to answer

Which do you consider yourself to be?

1. Gay, homosexual, lesbian, or same gender loving

2. Bisexual or two spirited

3. Straight or heterosexual

4. Other [Specify: ]

5. None of the above/unsure

6. Don’t know

7. Refuse to answer

What is your current relationship status? Are you…?

1. Single

2. Married to a man

3. Married to a woman

4. In a relationship with a man

5. In a relationship with a woman

6. Divorced or widowed

7. Don’t know

8. Refuse to answer

How many children less than 18 years of age live in your household?

Number of children_______________

1. Don’t know

2. Refuse to answer

In what zip code do you currently live?

_________

HIV Testing

Have you ever been tested for HIV? Do not count tests you may have had as part of a blood donation.

1. Yes

2. No

3. Don’t know

4. Refuse to answer

When was your last HIV test?

1. 0–2 months ago

2. 3–6 months ago

3. 7–12 months ago

4. More than 12 months ago

5. Don’t know

6. Refuse to answer

Was it a rapid test where you could get your results within a couple of hours?

1. Yes

2. No

3. Don’t know

4. Refuse to answer

Did you get the results of your last HIV test?

1. Yes

2. No

3. Don’t know

4. Refuse to answer

What was the result of your last HIV test?

1. Positive

2. Negative

3. Have not gotten the results yet

4. Don’t know

5. Refuse to answer

Are you currently being seen by a doctor, nurse, or other health care provider for medical care or treatment related to your HIV infection?

1. Yes

2. No

3. Don’t know

4. Refuse to answer

Invitation:

Thank you for answering these questions. This survey is part of a research study on behalf of the Centers for Disease Control and Prevention (CDC) regarding [INSERT TOPIC] and we would like to hear your views. As a token of appreciation, you will receive [INSERT INCENTIVE AMOUNT] [INSERT METHOD OF PAYMENT AND DATE]. This is an important research effort and we appreciate your assistance.

Closing for Ineligible Participants:

Thank you for answering all of the questions. You are not eligible to be in this study because [INSERT REASON]. We value your interest in this research study. Thank you for being willing to help us.

Closing for Eligible Participants Completing the Extended Survey:

Thank you for answering all of the questions. As a token of our appreciation for your participation in the study, we would like to give you $$$. Please verify for our records the following information: your name, mailing address, email address, and home phone number. [RESPONDENT VERIFIES CONTACT LIST INFORMATION PRE-PROGRAMMED TO APPEAR ON THE SCREEN].