Att 7_Symptom and Care Survey

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Identification of behavioral and clinical predictors of early HIV infection

(Project DETECT)

Attachment 7

Phase 2 HIV Symptom and Care Survey

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-New)

FP-1 Study ID: _______________

FP-2 Visit Date: MM/DD/YYYY

FP-3 Visit Day: _____ (e.g. Day 3, Day 7)

FP-4 Previous Visit Date: MM/DD/YYYY

CONSENT

[Show section if FP-3 = Day 3.]

We’ve already discussed the following question with you but would like to document your answer electronically. If you have any questions about what we’re asking, please talk to study staff before responding.

CT-1 We ask you to agree to freeze part of the blood and oral fluid specimens you give us at the CDC for future use.  We may use these samples for research in the future.  Nothing that could be linked to you will be kept with the blood.  We are not sure what studies might be done in the future.  They might include standard tests as done at hospitals, tests for HIV or other viruses or on your immune system (ability to fight infection).  We will not test for genetic problems or use the blood for cloning or commercial purposes.

I give consent for my blood to be stored at CDC for the future use as outlined above.
I DO NOT give consent for my blood to be stored at CDC for future research.

If CT-1 = No, participant has declined participation in the study. Screen will say, “Please pause the survey here and talk to study staff.” Study staff will discuss the response with the participant and address any questions or concerns. If participant does not want to participate, study staff will end the survey and withdraw participant from the study. If participant does want to participate and responded inaccurately for any reason, study staff will help the participant navigate back to the question and answer it correctly, so the participant can proceed with the remainder of the survey.

SYMPTOMS

SY-1 Since your last visit on [insert date], have you had any of these symptoms? Check all that apply.

1. Sore throat

2. Fever

3. Nausea

4. Vomiting

5. Diarrhea

6. Headache

7. Fatigue

8. Soreness or pain in your joints

9. Soreness or pain in your lymph nodes

10. Body Rash

11. I haven’t experienced any of these symptoms since my last visit

For any checked symptoms:

SY-2a-SY-2j You said you have had [insert symptom] since your last visit on [insert last visit date]. Do you have [insert symptom] today?

Yes

No

SY-3a-SY-3j When did you first experience this symptom?

MM/DD/YYYY

[If SY-2a-SY-2j = No:] SY-4a-SY-4j When did you last experience this symptom?

MM/DD/YYYY

If reported any symptoms:

SY-5 Did you go to a doctor or health care provider because of your symptom(s)?

Yes

No

SY-6 Did you miss work or school because of your symptom(s)?

Yes

No

SY-7 Were you hospitalized because of your symptom(s)?

Yes

No

HIV CARE

HC-1 Do you currently have a doctor or medical provider for HIV care?

Yes

No

HC-2 Since your last visit on [insert date], have you been to a doctor or medical provider for HIV care?

Yes

No

HC-3 When did you last see your HIV doctor or medical provider?

MM/DD/YYYY

HC-4 Are you currently taking medicines to treat your HIV?

Yes

No

[If HC-4 = No:] HC-5 Have you taken medicines to treat your HIV since your last visit on [insert date]?

Yes

No

[If HC-4 = Yes OR HC-5 = Yes:] HC-6 When did you start taking medicines to treat your HIV?

MM/DD/YYYY

[If HC-4 = No AND HC-5 = Yes:] HC-7 When did you stop taking medicines to treat your HIV?

MM/DD/YYYY

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