Form 0920-0572 Screener - Understanding Sexual Health Messaging among M

Form Approved
OMB Control No.: 0920-0572
Expiration date: 08/31/2021

Understanding Sexual Health Messaging among Men who have Sex with Men

Screener

Hello. Thank you for your interest in “the gay men’s sexual health evaluation.” My name is [name]. I am a Graduate Research Assistant at Georgia State University. We are conducting this evaluation to get feedback on a health communication effort to educate (or raise awareness with) gay and bisexual men about a germ.

We are recruiting men to participate in a face-to-face focus group that will be held [insert location].

If you are eligible and choose to participate, you will receive $40 gift card as a token of our appreciation for participating in the discussion.

To see if you are eligible to participate, we need to ask you some personal questions. It is your choice to answer these questions. Your answers will be kept private. You can refuse to answer a question or stop at any time.

If you are not eligible and/or choose not to be part of the focus group, all responses you give me today will be destroyed and you will not be contacted again.

These questions will only take a few minutes. May I ask you the questions now?

___ yes

___ no

So first let me ask, are you interested in participating in a focus group.

___ yes

___ no

[If yes, proceed with questions. If no, thank them for their time.]

Thank you. In order to determine eligibility I have a few questions.

1. What is your current age?

___________________________________________________________

[If under 18, thank them for their time and let them know they are not eligible for this particular evaluation.]

2. Do you currently describe yourself as male, female, or transgender?

___ Male

___ Female

___ Transgender
___ None of these

If you selected transgender, please select from below:

___ Transman

___ Transwoman

[If Female or Transwoman, thank them for their time and let them know they are not eligible for this particular study.]

3. Have you had sex with another man in the past 3 months?

___ yes

___ no

[If no, thank them for their time and let them know they are not eligible for this particular evaluation.]

4. Ethnicity

___ Hispanic or Latino

___ Not Hispanic or Latino

5. Which of the following do you identify?

___ American Indian or Alaska Native

___ Asian

___ Black or African American

___ Native Hawaiian or Other Pacific Islander

___ White/Caucasian

___ Other, please identify: __________________________________

6. What is your highest level of education?

___ Some or no high school

___ Completed high school

___ Some college

___ Completed 4-year college degree

___ At least some post-graduate

7. Have you ever used social networking apps, like Jack’d, Grindr, or Tinder to meet other men?

___ yes

___ no

[If not eligible] Thank you for your time and interest, you are not currently eligible at this time.

You are eligible to participate.

Would you like a reminder call or e-mail one or two days before our scheduled time? I will destroy your contact information after the completion of your participation to protect your confidentiality. [Note contact information under their nickname or an “R,” for reserved, if they do not provide a nickname at screening.]

Any questions before we end? Again, thank you for your interest and have a great day.

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: PRA 0920-0572