Participant Screening

Form Approved

OMB No: 0920-XXXX

Exp. Date: xx/xx/xxxx

Mobile Messaging Intervention to Present New HIV Prevention Options for Men who have Sex with Men: Randomized Controlled Trial

4a. Participant Screening Form

Thank you for your interest in the M³ mobile messages for men study. [Emory University is/Emory University and the University of Michigan are/Emory University and Public Health Solutions are] conducting this study is to test a smartphone app designed to deliver sexual health message to gay, bisexual and other men who have sex with men. If you are interested and eligible for this study, you will be asked to participate in a series of activities over the course of six months. These activities will include coming to [STUDY SITE FOR CITY], filling out 4 surveys about your sexual behavior, and interacting with a smartphone app. For each survey that you complete, you will receive a token of appreciation of up to $50.

To find out if you are eligible for this study, we need to ask you a few questions. It should not take more than 4 minutes. Some of these questions are personal, including questions about sexual activity and HIV status. Answering these questions is completely voluntary and you can refuse to answer a question or stop at any time. Would you like to continue to see if you are eligible for this study?

☐ Yes ☐ No

This study is funded through a cooperative agreement with the Centers for Disease Control and Prevention.

• [If “No,” participant is directed to a webpage reading:]

“You have indicated that you do not consent to taking the eligibility screener for our study. We require all respondents to consent to take the eligibility survey in order to participate in the study, so we cannot allow you to participate. Thank you for your interest in our study.

For information about HIV/AIDS, where you can find HIV testing, prevention and sexual health services, please visit AIDSVu.org.”

• [If “Yes,” participant is directed to a screener webform (below):

1. Are you able to read and understand English?

☐ Yes ☐ No

2. What is your current age? _____

3. What is the zip code of your current place of residence? __ __ __ __ __

4. What sex were you assigned at birth, on your original birth certificate?

☐ Male ☐ Female

5. How do you describe your gender identity?

☐ Male ☐ Female ☐ Male-to-female transgender (MTF) ☐ Female-to-male transgender (FTM)

☐ Other gender identity, specify: ____________________

6. Are you Hispanic or Latino?

☐ Yes ☐ No ☐ I don’t know

7. What is your race? You may choose more than one [select all that apply].

☐ American Indian or Alaska Native ☐ Asian ☐ Black or African American

☐ Native Hawaiian or Other Pacific Islander ☐ White

8. Do you own and use an Android or iOS smartphone?

☐ Yes ☐ No

9. In the past 12 months, that is since [mm/yyyy], have you had sex with a man?

☐ Yes ☐ No

10. In the past 12 months, that is since [mm/yyyy], have you had anal sex with a man?

☐ Yes ☐ No

11. What is your HIV status?

☐ HIV Negative ☐ HIV Positive ☐ Indeterminate ☐ I don’t know

12. [If HIV-Positive] In the past 6 months, that is since [mm/yyyy], did you test positive for the first time?

☐ Yes ☐ No

13. In the past 3 months, that is since [mm/yyyy], have you had anal sex with a man without using a condom?

☐ Yes ☐ No

14. [If HIV-negative] At any time in the past 3 months, that is since [mm/yyyy], have you taken PrEP (Truvada), the once-a-day pill to prevent HIV infection?

☐ Yes ☐ No

15. [If HIV-negative, has taken PrEP in past 3 months, had UPS in past 3 months]: At any time in the past 3 months, that is since [mm/yyyy], have you had anal sex without a condom when you were not taking PrEP?

☐ Yes ☐ No

16. Do you plan on moving out the [Atlanta/Detroit/NYC] area in the next 9 months?

☐ Yes ☐ No

17. Are you currently involved in any other HIV prevention study or program?

☐ Yes, specify study name: ___________________________

☐ No

Participant is INELIGIBLE IF:

IF #1 = “No” or;

#2 < 18, or;

IF #3 is not in Atlanta, Detroit or NYC MSAs, or;

IF #4 =/= “Male”, or;

IF #5 = “Female”, “MTF transgender,” or “FTM transgender” or;

IF #8 = “No”, or;

IF #9 = “No”, or;

IF #10 = “No,” or;

IF #11 = “Indeterminate,” or “I don’t know,” or;

IF #12 = “Yes”

If participant is eligible based on screener, participant will proceed to Appendix E – Contact Information Collection Form]

If participant is ineligible based on screener, participant will be directed to a page explaining that they did not meet the exclusion criteria, reading: “Thank you for your interest in our study. Unfortunately, based on the answers you provided, you are not eligible to participate. For information about HIV/AIDS, where you can find HIV testing, prevention and sexual health services, please visit AIDSVu.org” [proceed to Appendix I – Referrals to prevention and care services]

Public reporting burden of this collection of information is estimated to average 4 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-XXXX)