Form 0920-15AGK Att 3c HIV-Neg MSM Contact Info_English

Attachment 3c.

Pulse Contact Form - 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 3c HIV-Negative MSM Contact Info English

Public reporting burden of this collection of information is estimated to average 1 minute 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 (N HOUSE USE ONLY) :_______

Date: ______________

Recruiter___________

Notes:_____________

Location____________

PULSE Contact Form

Version 3.1

SECTION 1: TO BE COMPLETED AT TIME OF SCREENING:

We appreciate your interest in the study. I’m going to forward this information to the recruiting coordinator to determine if you are eligible for this study. If you are eligible, we will get back to you with more details. I’ll need your first name and phone number so we can reach you if you qualify.

1. What is your preferred name?

__________________________

2. Please provide me with a contact number where I can reach you with a reminder.

Phone 1 ____________________

1. Is there another number as well? Phone 2 ____________________

2. Is it okay for me to leave a message if you are not available to answer?”

Yes [ ] No [ ]

3. Is it okay to text your cell phone if you are not available to answer?”

Yes [ ] No [ ]

4. Is it ok to leave a call back number with someone who answers the phone?

Yes [ ] No [ ]

3. Is there an email address that you would like me to use to contact you?

1. YES Specify ____________________________

2. NO

4. What city/area are you calling from?

5. If known –An interviewer will be in our area the week of [DATE]. Would you be available then for an interview?

Yes

No

KEEP CONTACT INFORMATION SECURED.

IT IS PRIVATE INFORMATION.

SECTION 2: phone scheduling - once respondent is determined to be eligible

Thank you again for your interest in our study. [I am calling back about the research study on why some men/young men become infected with HIV and some do not.] You have been selected to participate in the study, if you would still like to.

Points to cover:

• The interview takes about an hour.

• The interview needs to be in person. We’ll have an interviewer in

  • [AREA] at

  • [LOCATION] on

  • [DATES].

• ADULTS: In order to be eligible and participate you will need to bring written verification that you have tested negative for HIV within the past 6 months.

  • If you don’t have written verification from your testing center or provider, you can get a free rapid HIV screening anytime between now and the interview

  • You may obtain a free HIV test at [LOCATION] right before the interview, give yourself at least XX number of minutes to get the test completed before our scheduled time

  • If you have had a negative test in the past six months you can ask your HCP to provide you verification to bring with you. This verification has to be from your HCP and have the date and results of the test as well.

  • We unfortunately will not be able to conduct an interview with you if we do not have the written verification from your HCP or an HIV testing facility.

• You will receive $40 cash/gift card following the interview.

• Your participation is completely voluntary and you do not have to answer any questions you do not feel comfortable answering.

• Participation in this research will in no way impact any care or services you may be receiving or are entitled to receive.

• Do you have any questions?

Version: xxxx OMB No. xxxxxxx Expiration date: xxxx Page 5 of 5