Form 0920-1080 Behavioral Survey Instrument

Form Approved
OMB No. 0920-1080
Expiration Date:xx/xx/xxxx

HIV Outpatient Study (HOPS)

Attachment 3b
Behavioral Survey Instrument screen shots

Public reporting burden of this collection of information is estimated to average 7 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)

0

Web ACASI Screen shots Male:

1

2

With a CORRECT AGE:

3

Select YES:

Select NO, SKIP:

4

5

Select YES:

Select NO, SKIP:

6

Select YES:

Select NO, SKIP:

7

HOPS

Saturday, September 8, 2018

Logout I Home

Smokeless tobacco products are placed in the mouth and nose and include chewing
tobacco, snuff, dip, snus (pronounced as "snoose") and dissolvable tobacco.
Have you ever used smokeless tobacco even one time? Select YES or NO.

Skip
You have completed 16% questions.

Cerner-

Select YES:

Select NO, SKIP:

8

Select YES:

Select NO, SKIP:

Select YES, NO or SKIP:

9

Select YES, NO or SKIP:

10

Select YES, NO, or SKIP:

Select YES, NO, or SKIP:

11

Select YES, NO, or SKIP:

Select YES, NO, or SKIP:

12

Slrturdlliy, September 8, 2018

HOPS
Logout I Home

In the last 6 months how often did you use pain killers such as Oxycontin, Vicodin,
morphine, or Percocet, either prescribed by a doctor or not?

Oncea week or less

You have completed 18% questions.

v Cerner

Select More than once a day, Once a day, More than once a week, Once a week or less:

Select Never:

13

Select YES, No, or SKIP:

Select YES, NO, or SKIP:

14

Select YES:

Select a Number 1 - 20

Select NO or SKIP:

Select “0 or >20” and get error message:

15

Fix Number 1 - 20

Select SKIP:

Select YES, NO, or SKIP:

Select YES, NO, or SKIP:

16

Select YES, NO or SKIP:

Select YES, NO or SKIP:

Select YES, NO or SKIP:

17

Select YES, NO or SKIP:

Select YES, NO or SKIP:

18

Select MEN only:

Select YES:

Select MEN and WOMEN:

Select WOMEN only:

Select NO or SKIP:

19

If number entered is not between
1-99 error message received:

Correct number to continue:

Select Enter:

20

Select YES:

Select NO:

Select 1 (HIV Positive):

Select 1 (HIV Negative):

21

Select 1 (do NOT know HIV status of all persons):

Select YES:

Select 1 (HIV Positive):

Select 1 (Some were HIV Negative):

22

Select 1 (do not know HIV status):

Select YES:

Select 1 (HIV Positive):

23

Select 1 (HIV Negative)

Select 1 (do NOT know HIV Status):

Select YES:

Select 1 (HIV Positive):

24

Select 1 (HIV Negative):

Select 1 (Do NOT know HIV status):

Select YES:

Select NO:

25

Select Very Difficult:

Select None, Some, All or SKIP:

Select None, Some, All or SKIP:

26

Select Any of the Selections above:

Select Any of the Selections above:

27

Select Any of the Selections above:

Select Any of the Selections above:

28

Select Any of the Selections above:

Select Office, Home, Other, or SKIP:

29

30

If selection for SEX is With MEN and WOMEN or WOMEN ONLY starting at page 19:

Select MEN and WOMEN:
(**see additional Word Doc starting here)

Select WOMEN only:

Select YES:

31

Select YES and enter HOW MANY.and continue. The following question is only an option if the MALE
has sex with WOMEN:

Select YES:

32

IF MEN and WOMEN was selected for sexual activities OR WOMEN ONLY…..continue as per the original
survey to the end:

33

Web ACASI Screen shots FEMALE – this document only shows the DIFFERNCES between the FEMALE
and MALE screen shots. If any of the screenshots are the same, they are not duplicated here except for
LOG IN and WELCOME screenshots:

34

36

Select WOMEN ONLY:

Select YES:

Select NO or SKIP:

37

Continue thru the rest of the questions….same as male to end of survey:

38