Focus Group Eligibility Screener Category 2

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

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

Attachment 3d# Focus Group Eligibility Screener Category 2

Public reporting burden of this collection of information is estimated to average 3 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)

Eligibility Screener- Category 2 Focus Group

AUTO1. Date screener was administered: __ __/ __ __ / __ __ __ __ (MM/DD/YYYY)

INT1. PCOC Staff ID __ __ __

INT2. Other Staff ID __ __ __

INT3. CBO Name __ __ __

INT4. Participant ID __ __ __

CONF1. Confirm that this participant has had a negative HIV test result in past 3 months (since MM/DD/YYYY).

• Yes, this participant had an HIV-negative test result in past 3 months

• No, this participant had an HIV-positive test result in past 3 months (or invalid/indeterminate test result)

CONF2. Confirm that this participant has had > 1 CBO-HPS referral or service in past 3 months (since MM/DD/YYYY).

• Yes, this participant has had > 1 CBO-HPS referrals in past 3 months

  

• No, this participant has not received any CBO-HPS referrals in past 3 months

CONF3. Confirm that this participant is high-risk (e.g., based on risk assessment or other information).

• Yes, this participant has self-reported as high-risk.

• No, this participant has not self-reported as high-risk.

CONF4. Confirm that this participant has not previously participated in a focus group for [PROJECT NAME].

• No, this participant has not previously participated in a focus group.

• Yes, this participant has previously participated in a focus group.

Only participants who have had a recent HIV-negative test result, have had > 1 CBO-HPS referrals/services recently, are high-risk, and have not previously participated in a focus group in [PROJECT NAME] can participate in the focus group. (Data collection software should not allow the staff person to proceed unless all criteria above have been met.)

CONF5. Specify which CBO(s) in [PROJECT AREA] provided CBO-HPS referrals or services to participant in past 3 months.

• Your CBO [CBO NAME]

• A different CBO [CBO NAME] (must have MOU with this agency for participant to be eligible)

• A different CBO [CBO NAME] (must have MOU with this agency for participant to be eligible)

___________________________________________________ __

Staff: I’d like to thank you again for your interest in the focus group. Remember that all information that you share will be kept private. First, I will ask you a few questions to determine if you are eligible to participate.

ES1. How old are you today? ___ ___ ___

[Refused = 777, Don't know = 999]

ES2. [THIS CBO NAME] and [OTHER CBO NAME] are both conducting focus groups with HIV-negative people in coming months. This focus group is part of a broader project called [PROJECT NAME]. The other project conducting the other focus groups is called [OTHER PROJECT NAME]. Have you participated in one of [OTHER PROJECT NAME]’s focus groups?

• Yes

• No

• Declined to answer

• Don’t know

If participant is < 13 years old, or they indicated they have participated in a focus group at a different CBO-OMP-funded grantees, skip to END1.

End 1. If the participant IS NOT ELIGIBLE:

Staff: Thank you for answering these questions. Unfortunately, you don’t meet the criteria to participate in our focus group. But thank you again for your time and we will be in touch about future studies if you are interested.

End Interview.

End 2. If the participant IS ELIGIBLE:

Staff: Congratulations! You are eligible to participate in our focus group. Let me tell you about it. [Proceed with the local IRB-approved consent process.]

C1. Did the participant provide written consent to take part in the focus group?

• Yes

• No

If no, skip to C2.

C2. We are interested in knowing why people do not want to participate in these focus groups. Would you mind telling me which of the following best describes the reason you do not want to participate? [Read choices. Check all that apply.]

• You don’t have time

• You don’t want to talk about these topics

• You’d rather not say why

• Some other reason

Staff: Thank you again for your time, we appreciate you considering our project. Please let us know down the road if you change your mind.

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