Form Approved
OMB No: 0920-0840
Exp. Date: 01/31/2019
AMSM and Transgender Youth 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)
Thank you for agreeing to talk to me about the Prevention Strategies Youth Focus Group Project, sponsored by the Centers for Disease Control and Prevention (CDC). My name is ___________, and I am one of the staff members from Fenway Health who works on the project.
How did you hear about the Prevention Strategies Youth Focus Group Project?
__________________________________
Great, I would like to take about 5 minutes of your time to tell you a bit about it. If you are still interested, I will ask you some questions to see if you are eligible (this is called screening). Is this an okay time talk?
Study Overview:
We are conducting one-time discussion groups to understand what young men attracted to men and transgender youth think about dating, relationships, sexual health, and HIV prevention. The focus group will take about two hours from start to finish.
SCREENING BRIEFING:
We want to talk with youth who come from a range of racial-ethnic backgrounds, youth from rural areas and cities, youth who are transgender and those who are not, and so on. In order to talk with a diverse group of youth we need to ask everyone who is interested in being interviewed a few screening questions.
Screening takes about 5 minutes and includes questions about your age, race-ethnicity, gender, and sexuality.
It is entirely your choice about whether or not to be screened. Also, you can skip questions and stop the screening process at any time.
In order to protect your privacy, we will label your answers with a unique ID number and not your name. Only the research team will have access to your answers. Participation in the screening process or ending your participation in the study at any time will not affect any services you receive at Fenway Health
At the end of the screening questions, we will ask you to provide us with your contact information. Your contact information will be used by the research team to schedule and confirm a focus group slot for you if you are eligible. If you are not eligible for the project at this time, we may contact you in the future if our eligibility criteria changes. It is entirely your choice to provide your contact information; however, if you do not provide contact information, you will be ineligible for the study
If you have any questions about this project, you can contact the Principal Investigator, Sean Cahill, at 888-242-0900 extension 6016 (toll free). You may also contact the Fenway Health Manager of Research Compliance at (617) 927-6400 if you have questions, concerns, or complaints about how you were treated during this screening conversation.
Do you have any questions? [If yes, please answer the questions. If no, please continue]
Based on the information I have provided, can I ask you a few questions to see if you are eligible? Saying “yes” means that you agree to be screened. Please know that you can end this screening at any point and/or skip any questions.
Yes [Continue below]
No – Declined Screening
If NO: Ask for reasons why:
No interest . . . . . . . . . . . . . . . . . . . . 01
Worried about anonymity . . . . . . . . 02
Rather not say . . . . . . . . . . . . . . . . . 03
Other . . . . . . . . . . . . . . . . . . . . . . . . 04
If other, specify __________________________________
What sex were you assigned at birth (what the doctor put on your birth certificate)? (check one)
Male
Female
Which of the following describes your gender identity, how you think about yourself? (check all that apply)
Male
Female
Transgender
Genderqueer/Gender non-conforming (do not identify as male, female, or transgender)
I am not sure of my gender identity
I do not know what this question is asking
If responses to questions 1 and 2 are not concordant then volunteer is TRANSGENDER
During your life, who have you had oral, vaginal/frontal, or anal sex with? (check one)
Males only
Females only
Both males and females
I have not had oral, vaginal/frontal, or anal sex
Who are you sexually attracted to? (check one)
Males only
Females only
Both males and females
I don't have sexual attractions
Which of the following best describes you?
Heterosexual (straight)
Gay or lesbian
Bisexual
Queer
Questioning (not sure of my sexual orientation)
If volunteer is not transgender and checked male on question 1 and checked male or both males and females on questions 3 or 4, then volunteer is MSM and has met sex and sexuality inclusion criteria ELIGIBLE MSM
If volunteer is transgender AND checked male or both males and females on questions 3 or 4, then volunteer has met gender and sexuality inclusion criteria ELIGIBLE TRANSGENDER
If neither ELIGIBLE box above is checked, then check INELIGIBLE
How old are you? __ __ If eligible MSM and < 13 or > 18 then Ineligible
If eligible transgender and < 13 or > 24 then Ineligible
What is your ethnicity?
Hispanic or Latino
Not Hispanic or Latino
What is your race? I am going to read a list. You can select one or more options from the list. Do you consider yourself …
RECORD ALL ANSWERS GIVEN BY RESPONDENT, BUT DO NOT PROBE FURTHER. OPTION #6, “OTHER,” MAY BE USED AS A RECORDING OPTION FOR NON-CONFORMING RESPONSES. OPTION #6 SHOULD NOT BE PRESENTED AS A RESPONSE OPTION.
{ONE OR MORE CATEGORIES MAY BE SELECTED}
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
OTHER
Where do you live? (check one)
City (big or mid-sized, if volunteered)
City (small, if volunteered)
Suburbs/burbs (of a big or mid-sized city, if volunteered)
Suburbs/burbs (of a small city, if volunteered)
Anywhere else, sometimes referred to as a rural or semi-rural area, e.g., few stoplights, need to drive miles to get basic supplies like groceries and gas.
INSTRUCTIONS: If any of the above ineligible boxes are checked, read the INELIGIBLE script. If none of the ineligible boxes are checked, read the ELIGIBLE script below.
INELIGIBLE- Based on your answers, you’re not eligible at this time to participate in these focus groups. If, over the next month or two, we change who we are looking to talk with, can we contact you?
No (Thank participant for their time and interest and end conversation)
Yes (Skip to last page of form)
ELIGIBLE- Based on our conversation today, you are eligible for the focus group project. If you want to participate, I will get your contact information and then will let you know when, where, and how to participate.
NOTE: THIS PAGE IS ONLY TO BE FILLED OUT IF A PERSON MEETS ELIGIBILITY AND IS INTERESTED IN BEING IN A FOCUS GROUP.
Preferred name (first name you go by): ______________________
Date of Birth*: |_____|_____|--|_____|_____|--|_____|_____|_____|_____|
*With the completion of this box, this document now contains confidential identifying information and must be stored separately from other data collected for this project.
What’s a good way to contact you (schedule/remind)? (must provide 1 form of contact information)
Phone:_______________________ (home / cell / other) (circle phone type)
What name should we use to ask for you at this number? _____________________
What pronoun should we use to ask for you at this number? _________________
Is it OK to say we are calling from Fenway Health?
No. (Just say the facilitator’s/person calling name and phone number.)
Yes
And if we miss you, is it OK to leave a voice message?
No, do not leave a voice message.
Yes
Is it OK to text? (if cell phone provided)
No, do not text
Yes
Email (optional): ____________________________________________________
OK to Email
Facebook (optional): ________________________________________________
OK to send Facebook message
Investigator/Designee:
_________________ _______________ _________
Signature Print Name Date
Data Entry Checklist:
Screening data entered into REDCap
If applicable, screening ID assigned and listed on all screening forms
Contact information for SCREENED participants entered into REDCap database
Screener data stored in screening binder
Eligible – Contact info stored in the screening contact info binder under “Eligible”
Ineligible – Contact info stored in the screening contact info binder under “Ineligible”
Declined Screening – Contact info stored in the screening contact info binder under “Declined Screener”
Link File – Screening ID and First and Last Name added to Link File
Checklist added to QC log
Notes:
screening date: |_____|_____||_____|_____||_____|_____|_____|_____| TIME OF CONTACT:_____________ AM/PM
Screener id# :______ RESEARCH STAFF INitials: |_____|_____ screening phase: In Person | Phone
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Sophia Geffen |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |