Form 0920- Project NICE: Navigating Insurance Coverage Expansion -

Form Approved

OMB No: 0920-XXXX

Exp. Date: xx/xx/20xx

Project NICE: Navigating Insurance Coverage Expansion

Attachment 5: Participant Eligibility Form

Public reporting burden of this collection of information varies with an estimated average of 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: OMB-PRA (0920-new)

Eligibility Screener

Administration: To be completed by a partner agency staff member.

Partner agency ID: _________________________

Participant Record ID: __________________________________

Date of Eligibility Screening / “Today’s Date” __________________________________

Partner agency staff reads: “I am going to ask you a series of questions that determines if you qualify for this study. Please answer all of the questions to the best of your ability.. We recognize that some of the questions might ask for sensitive information. If you cannot or do not wish to answer any of them, that is ok. However, in order to participate in the study, we need you to answer all the questions so we know if you are eligible.”

1) What is your date of birth (month/day/year)? __________________________________

2) How old are you (years)?

__________________________________

3) What is your race? (select all that apply)  American Indian or Alaska Native

 Asian

 Black or African American

 Native Hawaiian or other /Pacific Islander

 White

4) Do you identify as Hispanic/Latin(x)?  Yes

 No

5) What sex were you assigned at birth, on your original birth certificate?

 Male

 Female

6) How do you describe your gender identity?  Male

 Female

 Male to female transgender (MTF)

 Female to male transgender (FTM)

 Other gender identity (specify) _______

 Decline

7) Will you be living in the Chicagoland area until  Yes

[REDCap adds date 18 months from today]?  No

8) What is your current zip code? ___________________

9) Have you had anal or oral sex with a man in the  Yes

past two years?  No

10) Have you already enrolled in this study?  Yes

 No

For participants to be eligible for this study, they must meet all of the following criteria:

1. Be 18 or older at the date of eligibility screening

2. Identify as Hispanic/ Latin(x)/ Black/ African American [Race=3 AND/OR Ethnicity=1] AND [[Sex at birth =1 AND Gender identity =2,3,5 OR Sex at birth =2 AND Gender identity =1,4,5]] AND [Sex w/man=1]

3. Current Zip code belongs to one of the zip codes in the Chicago MSA.[ 60290 60601 60602 60603 60604 60605 60606 60607 60608 60609 60610 60611 60612 60613 60614 60615 60616 60617 60618 60619 60620 60621 60622 60623 60624 60625 60626 60628 60629 60630 60631 60632 60633 60634 60636 60637 60638 60639 60640 60641 60642 60643 60644 60645 60646 60647 60649 60651 60652 60653 60654 60655 60656 60657 60659 60660 60661 60664 60666 60668 60669 60670 60673 60674 60675 60677 60678 60680 60681 60682 60684 60685 60686 60687 60688 60689 60690 60691 60693 60694 60695 60696 60697 60699 60701 60706 60707 60803 60804 60805 60827]

4. Currently live in Chicago and plan on living there for the next 18 months [Chicagoland=1]

5. Have not previously enrolled in this study [enrolled=2]

[REDCap branching logic will determine if participant is eligible]

Participant is eligible for study  Yes

 No

IF participant is ELIGIBLE: Have participant sign the informed consent form, and begin participant profile form.

IF participant is INELIGIBLE: say: “I’m sorry. You are not eligible for this study”. Provide token of appreciation.