Form 0920 Participant Enrollment Form

Form Approved

OMB No: 0920-XXXX

Exp. Date: xx/xx/20xx

Project NICE: Navigating Insurance Coverage Expansion

Attachment 7: Participant Enrollment Form

Public reporting burden of this collection of information varies with an estimated average of 35 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)

Randomization

Administration: To be completed by partner agency staff.

1) Did client read and sign the informed consent?  Yes

 No

2) Was client recruited during an intervention or  Intervention

control venue or clinic visit?  Control

Contextual Information

Administration: To be completed by study participant.

Instructions: Please read the following questions, and answer to the best of your ability. You may skip any question that you do not want to answer.

1) What is your current housing situation?  Living in my own place

 Staying with a family member

 Staying with a friend

 Temporary shelter

 Homeless/ street/ empty building/ my car

 Foster/ group home

 Other

2) How difficult is it for you to meet monthly  Not at all difficult

payments on bills?  Not very difficult

 Somewhat difficult

 Very difficult

3) Have you ever been incarcerated or in jail for longer than one night?

 Yes

 No

Pre-Exposure Prophylaxis (PrEP)

Instructions: Please tell us how much you agree or disagree with each of these statements. You may skip any question that you do not want to answer. PrEP is daily medicine that may reduce a person’s chance of getting HIV.

1) PrEP should only be given to people who are unable to make their partners use condoms.

• Disagree

• Somewhat Disagree

• Neither Agree nor Disagree

• Somewhat Agree

• Agree

2) Some people who are on PrEP use it as an excuse to have sex without a condom.

• Disagree

• Somewhat Disagree

• Neither Agree nor Disagree

• Somewhat Agree

• Agree

3) PrEP should be given to anyone who wants to take it for HIV prevention.

• Disagree

• Somewhat Disagree

• Neither Agree nor Disagree

• Somewhat Agree

• Agree

4) PrEP will make people less responsible.

• Disagree

• Somewhat Disagree

• Neither Agree nor Disagree

• Somewhat Agree

• Agree

5) I would worry that taking PrEP might affect how people see me.

• Disagree

• Somewhat Disagree

• Neither Agree nor Disagree

• Somewhat Agree

• Agree

6) I would worry that people who know I take PrEP might tell others.

• Disagree

• Somewhat Disagree

• Neither Agree nor Disagree

• Somewhat Agree

• Agree

Substance Use

Instructions: Please answer “Yes” or “No” to the following questions. You may skip any question that you do not want to answer.

In the past THREE (3) MONTHS have you used:

1) Tobacco  Yes

Including cigarettes, chewing tobacco, cigars, etc.  No

2) Inhalants  Yes

Such as nitrous, glue, petrol, paint thinner, etc.  No

3) Hallucinogens  Yes

Such as LSD, acid, mushrooms, PCP, Special K, etc.  No

4) Alcoholic beverages  Yes

Including beer, wine, spirits, etc.  No

5) Cannabis  Yes

Including marijuana, pot, grass, hash, etc.  No

6) Cocaine  Yes

Such as coke, crack, etc.  No

7) Amphetamine type stimulants  Yes

Such as speed, diet pills, ecstasy, etc.  No

8) Sedatives or Sleeping pills  Yes

Such as valium, serepax, rohypnol, etc.  No

9) Opioids  Yes

Such as heroin, morphine, methadone, codeine, etc.  No

10) Any drug by injection (NON-MEDICAL USE ONLY)  Yes

 No

11) Other substances  Yes

 No

12) Would you like a referral to substance use  Yes

treatment?  No

Mental Health

Instructions: Please answer how much or how often during the past TWO (2) WEEKS, you been bothered by the following problems. You may skip any question that you do not want to answer.

None/Not at all Less Several More Nearly

than a day or two days than half the days every day

1) Little interest or pleasure in     

doing things.

2) Feeling down, depressed, or     

hopeless.

3) Feeling nervous, anxious,     

frightened, worried, or on edge.

4) Feeling panic or being     

frightened.

5) Avoiding situations that make     

you anxious.

(Skip pattern here: Depression questions and T-score info will appear if a participant reports “several days,” “more than half the days,” or “nearly every day” to question 2 above in the mental health section).

Depression

Instructions: Please answer how much or how often in the past SEVEN (7) DAYS, you had the following feelings. You may skip any question that you do not want to answer.

Never Rarely Sometimes Often Always

1) I felt worthless     

2) I felt that I had nothing to look     

forward to

3) I felt helpless     

4) I felt sad     

5) I felt like a failure     

6) I felt depressed     

7) I felt unhappy     

8) I felt hopeless     

(Skip pattern here: Anxiety questions and T-score info will appear if a participant reports “several days,” “more than half the days,” or “nearly every day” to question 3 above in the mental health section).

Anxiety

Instructions: Please answer how much or how often in the past SEVEN (7) DAYS, you had the following feelings. You may skip any question that you do not want to answer.

Never Rarely Sometimes Often Always

1) I felt fearful     

2) I felt anxious     

3) I felt worried     

4) I found it hard to focus on     

anything other than my anxiety

5) I felt nervous     

6) I felt uneasy     

7) I felt tense     

DEPRESSION SCORES (calculated by REDCap)

Depression Total/Partial Raw Score __________________________________

Depression T-Score: __________________________________

Depression T Score-Interpretation:  None to slight (t score < 16)

 Mild/several days (t score 16-19)

 Moderate/more than half the days (t score 20-27) (offer a mental health referral)

 Severe/nearly every day (t score ≥28) (offer a mental health referral)

ANXIETY SCORES (calculated by REDCap)

Anxiety Total/Partial Raw Score: __________________________________

Anxiety T-Score: __________________________________

Anxiety T-Score Interpretation:  None to slight (t score < 16)

 Mild/several days (t score 16-19)

 Moderate/more than half the days (t score 20-27) (offer a mental health referral)

 Severe/nearly every day (t score ≥28) (offer a mental health referral

6) Would you like a referral to mental health  Yes

counseling?  No

=====================================================================

Health Care System

Instructions: Please tell us how much you agree or disagree with each of these statements. You may skip any question that you do not want to answer.

1) The health care system does its best to make  Agree

patients’ health better.  Somewhat Agree

 Neither agree nor Disagree

 Somewhat Disagree

 Disagree

2) The health care system covers up its mistakes.  Agree

 Somewhat Agree

 Neither agree nor Disagree

 Somewhat Disagree

 Disagree

3) Patients receive high quality medical care from the  Agree

health care system.  Somewhat Agree

 Neither agree nor Disagree

 Somewhat Disagree

 Disagree

4) The health care system makes too many mistakes.  Agree

 Somewhat Agree

 Neither agree nor Disagree

 Somewhat Disagree

 Disagree

5) The health care system puts making money above  Agree

patients’ needs.  Somewhat Agree

 Neither agree nor Disagree

 Somewhat Disagree

 Disagree

6) The health care system gives excellent medical care.  Agree

 Somewhat Agree

 Neither agree nor Disagree

 Somewhat Disagree

 Disagree

7) Patients get the same medical treatment from the  Agree

health care system, no matter the patient’s race or  Somewhat Agree

ethnicity.  Neither agree nor Disagree

 Somewhat Disagree

 Disagree

8) The health care system lies to make money.  Agree

 Somewhat Agree

 Neither agree nor Disagree

 Somewhat Disagree

 Disagree

9) The health care system experiments on patients  Agree

without them knowing.  Somewhat Agree

 Neither agree nor Disagree

 Somewhat Disagree

 Disagree

Self-Efficacy

Instructions: Please choose from the scale of 1 to 5, with 1 being 'very sure I cannot' to 5 being 'very sure I can', for each of the following questions. You may skip any question that you do not want to answer.

1) How sure are you that you can take care of your  1 Very sure I cannot

health?  2

 3

 4

 5 Very sure I can

2) How sure are you that you can do better with taking  1 Very sure I cannot

care of your health?  2

 3

 4

 5 Very sure I can

3) How sure are you that you can take care of your  1 Very sure I cannot

health even if you were very tempted not to?  2

 3

 4

 5 Very sure I can

You are now finished with answering the questions in this section. Please return this device to the person who is helping you.

=========================================================================

Insurance Enrollment Information and Intervention

Administration: To be completed by partner agency staff.

Instructions: Please read the following questions aloud to the participant.

1. Are you currently enrolled in health insurance? When we say health insurance we mean private plans (through work, the marketplace, or parents/guardians), public plans (such as Medicaid, Integrated Care Program, Family Health Plan, Managed Long Term Services, Medicare Medicaid Alignment or Medicare), or other plans (VA).

 Yes (move to question 2)

 No (offer intervention or control activity and move to question 3 for intervention group or 4 for control group)

 I don't know (offer intervention or control activity and move to question 3 for intervention group or 4 for control group)

2) You shared that you are enrolled in insurance, when  0-3 months ago

was the last time you saw a health care provider not  3-6 months ago

in the emergency room, pharmacy clinic, or urgent care?  Greater than 6 months ago

AT THIS TIME PARTNER AGENCY STAFF OFFERS HEALTH INSURANCE ASSISTANCE TO INTERVENTION GROUP PARTICIPANT OR BOOKLET TO CONTROL GROUP PARTICIPANT.

3) (For intervention group only) As a result of the study, the Client was:

 Enrolled in health insurance [SKIP TO Q.5]

 Changed to a different insurance plan [SKIP TO Q6]

 Assisted with learning how to use their insurance [SKIP TO Q8]

 Began enrollment but could not complete enrollment [SKIP TO Q12]

 Declined insurance services [SKIP TO Q14]

4) (For control group only) As a result of the study, the client was:  Given health insurance enrollment information [SKIP to Q15]

5) If enrolled, what type of plan was the client  Medicaid (Family Health)

enrolled in?  Medicaid (Integrated Care)

 Medicaid (Medicare-Medicaid Alignment)

 Medicaid (Long-term services & supports)

Medicare

 Market Place Plan – Bronze level

 Market Place Plan – Silver level

 Market Place Plan – Gold or Platinum level

 VA, Veterans Administration

[SKIP to Q.9]

6) If plans were switched, what type of plan was the  Medicaid (Family Health)

client switched to today?  Medicaid (Integrated Care)

 Medicaid (Medicare-Medicaid Alignment)

 Medicaid (Long-term services & supports)

 Market Place Plan – Bronze level

 Market Place Plan – Silver level

 Market Place Plan – Gold or Platinum level

 VA, Veterans Administration

[SKIP to Q.9]

7) Ask participant: “Please tell me your reasons for changing your health insurance plan. _______________________________________

8) If client was helped with learning how to navigate

their insurance, what information was provided? _______________________________________

9) What is the name of the client’s plan: _______________________________________

(This should be the plan you either (1) enrolled

them in (2) they were switched to or (3) you

helped them learn how to navigate. )

10) Date plan goes into effect: _______________________________________

11) What is the client’s insurance enrollment number _______________________________________

[SKIP to Q 15]

12) If enrollment or switching a plan was started but not completed, why was it not completed?

 Client did not have all necessary information

 Client wanted or needed to leave

 The event was scheduled to end

 Other______________________________

13) What information was given to the client if you were unable to complete the insurance services session?

 Client was given individual insurance roadmap

 Client was given the link to resources or additional information

 Client was given information to follow up at a later date (not with the interventionist)

 Other______________________________

[SKIP to Q 15]

14) Please tell me your reasons for declining our insurance services. ________________________

15) Did client sign a release of information?  Yes

 No

Partner agency staff/navigator name: ______________

Total time of intervention: _________________

(calculated field: End time-start time [Q15]

Participant Time and Travel

Administration: To be completed by study participant.

Instructions: Please read the following questions, and answer to the best of your ability. You may skip any question that you do not want to answer.

1. About how far is it (one way) from your home to [this venue]?

______Miles ______If unknown, ask for home zip code

2. About how much time (one way) did it take for you to travel from your home to here?

______Hours _____Minutes

3. How did you get here today?

____Public bus

____Train (CTA L, The “L”)

____Taxi

____Private car

____Other: please specify_______________

4. How many people were traveling with you, if you traveled by a car or taxi?

______People

5. Was visiting this place the (check one):

____Sole or major purpose of your travel from home

____One of many equally important reasons for this travel

____Just a minor part of the whole purpose of this travel

6. Would you be normally working for pay at this time?

____Yes ____No

Participant Satisfaction Survey

Administration: To be completed by study participant after the intervention exposure or receipt of health insurance information.

Instructions: Please answer how satisfied you were this this experience today. You may skip any question that you do not want to answer.

How satisfied were you with the following. :

Very

Dissatisfied Dissatisfied Neither Satisfied Satisfied Very Satisfied

Nor

Dissatisfied

1) The amount of time

you had with the insurance

navigator     

2) The stipend amount in relation

to how much time you spent     

3) How much information was

given to you prior to enrolling

in the study     

4) The health insurance services

you received     

5) Do you have any other feedback for study staff? __________________________________________

Please return the device back to the partner agency staff.

Partner agency staff will provide participant with token of appreciation.

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