Eligibility Screener

Form Approved

OMB No: 0920-0840

Exp. Date: 01/31/2019

Attachment 6: Eligibility Screener

Public reporting burden of this collection of information is estimated to average 1 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)

Date: ____/____/_____

Time: ______________ □ AM □ PM

Resilience and Transgender Youth Eligibility Phone Screener

Interviewer: Thank you for your interest in our research study. I am going to ask you a few questions to see if you qualify to participate at this time.

1. In what month and year were you born? _______ (Month)/_________ (Year)

2. Are you… ?

□ Hispanic or Latino

□ Not Hispanic or Latino

3. Which of these categories would you identify as your race? (Choose all that apply)

□ American Indian or Alaska Native

□ Asian

□ Black or African American

□ Native Hawaiian or Other Pacific Islander

□ White

4. How do you identify your gender? ________________________________

5. What sex were you assigned at birth, meaning on your original birth certificate?

□ Male □ Female □ I don’t know

________________________________________________________________________________

 was born between 1992 and 2003,

 the sex on the birth certificate is different from the gender reported (e.g. male & transwoman; female & man; male & genderqueer)

Interviewer: One moment while I check to see if you qualify.

[PLACE PARTICIPANT ON HOLD WHILE SEEING IN PARTICIPANT MEETS STUDY CRITERIA, FITS THE AGE RANGE, AND FITS INTO A SAMPLING QUOTA NOT YET FILLED.]

[IF ELIGBILE]

Interviewer: Great! Based on your answers, you qualify to participate in our study, which is funded by the Centers for Disease Control and Prevention (CDC). Let me tell you a little bit more about what that entails.

We are doing a research study about the parts of transgender youth’s lives that help them to be strong, happy, and healthy. A research study is a way to learn more about people. This research study will help scientists understand more about the health and wellbeing of transgender and other gender variant youth. If you decide that you want to be part of this study, we will invite you to take part in an interview with a member of our study team. Interviews last between 60 and 90 minutes. We will audiotape the interview to make sure we get all your words right. During the interview, we will talk to you about what in your life helps you to feel strong, happy, and healthy. If at any time you decide you do not want to continue, you are allowed to stop the interview. Your answers will be kept private and will be identified only by an assigned number, and not your name, in documentation. When you finish the interview, we will give you a $50 gift card as a thank you for participating in this research study. Does that sound like something you would like to participate in?

[IF YES] Great, let’s set up a time for your interview. [SCHEDULE INTERVIEW]. Thank you! Additionally, we like to give folks a reminder email or call the day before the interview. Is there an email address or cell phone number that would be best to reach you for a reminder?

Date/ Time of Interview: ________________

Email Address or Cell Number: _______________________________

What name should I use in reminder messages? _____________________________________

[IF NO] Okay, no problem. Thanks so much for taking the time out of your day to speak with me. Take care!

[IF NOT ELIGIBLE]

Interviewer: Unfortunately, you are not eligible for participation in our study at this time. Thank you so much for speaking with us, and have a great day!

[IF AGE/ GENDER OK, BUT DOES NOT FIT SAMPLING QUOTA]

Interviewer: At this time, you do not currently qualify for participation in our study, however, we may be able to include you in the future. Would you like us to keep your information on file if interview spots open up in the next few months?

[IF YES] Date: ____________________ Email Address or cell number: _________________________

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