Eligibility Screener

Form Approved

OMB No. 0920-0840

Expiration Date: 1/31/2019

Project Engage: Engaging Gay “Community” Activism for Syphilis Prevention

Generic Information Collection Request under OMB #0920-0840

Attachment #5a

Eligibility 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 (0920-0840)

Introduction

Thanks for your willingness to answer some eligibility questions. We are asking African American gay, bisexual, and other men who have sex with men to take part in a research study about their ideas of community, identity, and sexual health.

This survey is sponsored/funded by the Centers for Disease Control and Prevention (CDC). The purpose of the research is to improve sexual health outreach to these groups.

To see if you are eligible for this study, I need to ask you a few questions. 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

Which of the following best describes your race?

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Native Hawaiian or Other Pacific Islander

5. White

6. Don’t know

7. Refuse to answer

Which of the following best describes your ethnicity?

1. Hispanic or Latino

2. Not Hispanic or Latino

Have you had oral or anal sex with a man in the past 12 months?

1. Yes

2. No

3. Refuse to answer

In what county/parish do you currently live?

_________

INTERVIEWER INSTRUCTION: ELIGIBLE IF:

(All must be checked)

• Age18 years or older

• Male

• NON-HISPANIC, African American or Black

• Has sex with men IN PAST 12 MONTHS (MSM)

• Lives in one of the following counties/parishes : Montgomery county, district of Columbia, prince George’s county, Arlington county, Alexandria county, Orleans parish, Jefferson Parish, St. Bernard Parish

Thank you for answering these questions.

If eligible:

"You are eligible to take part in this study. As a part of the study you will be asked to participate in a phone interview that may last up to one hour. You will need access to a phone and private location to participate in the interview. We will also be asking you for your email address in order to deliver your token of appreciation, but the information will be destroyed once the study is complete. Are you interested in taking part in the study?"

If “Yes”

We need to collect some contact information now so we can reach you regarding scheduling.

If “No”

We appreciate your interest in this study and willingness to consider helping to improve STD prevention efforts in our community. Thank you.”

For those who are ineligible:

“I’m sorry but you are not eligible to take part in this study at this time. There are many possible reasons why people are not eligible to be in the study, reasons that were decided earlier by the researchers. We appreciate your interest in this study and willingness to consider helping to improve STD prevention efforts in our community. Thank you.