Form 0920-015AGK Att 3a HIV-Neg MSM Screener_English

Attachment 3a.

Pulse Screener - English

Form Approved

OMB No: 0920-New

Exp. Date: XX/XX/XXXX

Understanding Barriers and Facilitators to HIV prevention for

Men Who Have Sex with Men (MSM) – Pulse Study

Attachment 3a HIV-Negative MSM Screener English

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)

ID:_________________

Date: ______________

Minor/Adult________

Hisp/AA___________

Testing Proof: Y / N

Recruiter___________

Location____________

PULSE Screener

Version 3.2

Narrative FAQ: Let me tell you a little about the study. The Centers for Disease Control and Prevention (CDC) is conducting research into how HIV impacts men and how they avoid getting HIV. The study consists of a face-to-face interview that should take about an hour of your time in a place convenient to you. I have a few questions for you to make sure you qualify for the study.

1. How old are you? _________

1. 13-17

   

2. 18-24

   

   1a adults only Why do you think you qualify for this study?

   
   
   

3. 25-35

4. 36-44

5. 45+

2. IF NOT CLEAR ABOVE Where did you learn about this study?

1. Friend/Flyer/Online Ad

2. Person/Place where status/Eligibility is verified [Specify_________________]

3. Other ________________

5. Do you consider yourself to be male or female?

1. ____ Male

2. ____ Female

3. ____ Other: _________________

5. Do you consider yourself to be transgender?

[ ] No
[ ] Yes

[ ] Refused to answer

[ ] Don’t Know

5. Do you consider yourself to be of Hispanic, Latino/a, or Spanish origin? (Interviewer, code one)

[ ] No
[ ] Yes

[ ] Refused to answer

[ ] Don’t Know

5. Which racial group or groups do you consider yourself to be in? You may choose more than one option. [READ CHOICES. CODE ALL THAT APPLY.]

1. ____American Indian or Alaska Native

2. ____Asian

3. ____Black or African American

4. ____Native Hawaiian or Other Pacific Islander

5. ____White

6. ____Refused to answer

7. ____Don’t know

IS Caller a MINOR OR AN ADULT?

MINOR

ADULT

Minor: Have you ever been tested for HIV? Yes b) No 8a. What were the test results the last time you were tested? 9. Minor: Are you a ward of the state, in foster care or live in a state run facility? a. Yes b. No 10. Minor: Are you sexually attracted to... Guys Girls Both Don’t Know Refused to answer

8. Adult: Have you ever been tested for HIV? Yes b) No 8a. What were the test results the last time you were tested? 8b. When was that test? Month______ Year ________ If more than 6 months from interviewer travel date 8c Do you have those results in writing? Yes No 9. ADULT In order to be eligible for this study you would need to be tested/ retested and bring proof of negative test results within the past 6 months. Is this something you would be willing to do? a. Yes b. No 10- Adult During the past 6 months have you had anal or oral sex with a man? Yes No Don’t Know Refused to answer

11. That’s all the questions I have, I need to collect some contact information now so we can reach you.

Continue to contact sheet then return here after call is finished to complete eligibility

INTERVIEWER INSTRUCTION: ELIGIBLE IF:

(All must be checked)

• R is Male,

• HIV negative Verified via HD/CBO or willing to verify for Adults or Negative/not tested for Minors

• 13 or older

• AA or Latino

• MSM (minors=10 a or 10c or adults = 10a)

• Can speak English OR Spanish Well or Very Well

• Able to complete In Depth Interview (does not sound/appear to be under the influence of drugs or alcohol/disoriented/confrontational/ has much trouble with screener questions/ angry)

• Minors – not a ward of the state 9b=No

FAQs Tell them more about the study:

• The purpose of this research project is learn about how men get or do not get HIV if they have sex with other men

• Funding for this study is provided by the Centers for Disease Control and Prevention (CDC).

• We expect to enroll about 150 people in 5 cities across the country.

• The Interview should take about an hour, depending on your answers.

• The Interview will be audio recorded so researchers can review the information—no names will be used.

• You will receive a [gift card for $40/$40 cash.]

• All information will be kept private.

• Your care or services from any clinic or organization will not be affected in any way by your decision whether or not to participate in the study.

Version :xxx OMB No. xxxxx Expiration date: xxxxx Page 3 of 6