Eligibility Screening Form - Reverification

Form Approved

OMB No: 0920-0840

Exp. Date: 01/31/2019

Development of a Mobile Messaging Intervention for Men who have Sex with Men:

Formative Study

2a. Screening Questionnaire

“Thank you for your interest in the Mobile Messaging Intervention for Men Who Have Sex With Men study, which is focused on learning more about how to craft effective sexual health messages for men who have sex with men. We would like to let you know that funding for this study is provided by the Centers for Disease Control and Prevention. To find out if you are eligible for this study, we need to ask you a few questions. It should not take more than 4 minutes. Some of these questions are personal, including questions about sexual activity and HIV status. Answering these questions is completely voluntary and you can refuse to answer a question or stop at any time. If you answer the questions and we determine that you are eligible, you will then be offered the opportunity to participate in the research study, which includes coming to [STUDY SITE FOR CITY] to take part in either a 90-minute focus group discussion or a 90-minute interview about similar topics. If you complete one of the longer 90-minute activities, you will receive a $40 as a token of appreciation. Would you like to continue to see if you are eligible for this study?”

• [If “No,” participant is directed to a webpage reading:]

“You have indicated that you do not consent to taking the eligibility screener for our study. We require all respondents to consent to take the eligibility survey in order to participate in the study, so we cannot allow you to participate. Thank you for your interest in our study.”

• [If “Yes,” participant is directed to the below screener webform]

• [If participant is ineligible based on screener, participant will be directed to a page explaining the exclusion criteria, reading:]

“Thank you for filling out this eligibility screener. Unfortunately, based on the answers you provided, you are not eligible for this study. Thank you for your interest in our study.”

For this study, we are recruiting a diverse group of men who have sex with men (MSM) to discuss your thoughts and opinions about the quality of messages promoting sexual health and prevention.

If you are eligible to participate in the study, you will directed to a website where you can sign up to be a participant. Once your eligibility is confirmed, study staff will contact you to schedule your participation.

1. Age: ______

2. Current Gender Identity (Select one):

☐ Male

☐ Female

☐ Transgender

☐ Other

3. Sex assigned at birth :

☐ Male

☐ Female

4. What zip code you live in? __________

5. Do you own and use an Android or an iOS smartphone? :

☐ Yes

☐ No

6. In the past 6 months, have you had sex with any male partner? :

☐ Yes

☐ No

7. Do you consider yourself to be Hispanic or Latino? :

☐ Yes

☐ No

8. Which racial group or groups do you consider yourself to be in? You may choose more than one option [check all that apply] :

☐ American Indian or Alaska Native

☐ Asian

☐ Black or African American

☐ Native Hawaiian or Other Pacific Islander

☐ White

9. What is your HIV status? :

☐ HIV Positive

☐ HIV Negative

☐ Don’t Know

☐ Refuse to Answer

10. Do you use condoms consistently and correctly, every time you have sex? :

☐ Yes

☐ No

☐ Don’t Know

11. Are you currently taking PrEP?

☐ Yes

☐ No

☐ Don’t know

12. If you’re taking PrEP, do you always take it exactly as directed by your prescriber, and never miss doses? :

☐ Yes

☐ No

☐ Don’t Know

Public reporting burden of this collection of information is estimated to average 4 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)