Focus Group Eligibility Questionnaire Category 1

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

“Community-based Organization Outcome Monitoring Projects for CBO HIV Prevention Services Clients”

Attachment 5i#

Category 1 Focus Group Questionnaire

Public reporting burden of this collection of information is estimated to average 1 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)

Category 1 Pre-Focus Group Questionnaire

1. Please tell me the month and year of your date of birth?

__ __/__ __ __ __ (MM/YYYY)

2. How old are you?

__ __ __

3. Are you: (Choose one)

• Hispanic or Latino

• Not Hispanic or Latino

• Decline to answer

• Don’t know

4. What is your race? (Choose all that apply)

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Pacific Islander

• White

• Declined to answer

• Don’t know

5. What was your sex at birth? (Choose only one.)

• Male

• Female

• Declined to answer

• Don’t know

6. Do you consider yourself to be male, female, or transgender? (Choose only one.)

• Male

• Female

• Transgender (MTF)

• Transgender (FTM)

• Transgender (not specified)

• Declined to answer

• Don’t know

7. Do you think of yourself as:

• Lesbian or gay

• Straight, that is, not gay or lesbian

• Bisexual

• Something else

• Declined to answer

• Don’t know

8. Are you attracted to other males?

• Yes

• No

• Declined to answer

• Don’t know

9. When did you first test positive for HIV?

___ ___/___ ___ ___ ___

• Declined to answer

• Don‘t know

10. What was the date of your most recent appointment with an HIV medical care provider?

___ ___/___ ___/___ ___ ___ ___ (MM/DD/YYYY)

• Declined to answer

• Don’t know

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