Contact information form

OMB# 0920-1091

Expiration Date: 09/30/2021

Attachment 3b Contact Information Form

Assessing the acceptability and adoptability of HIV-1 pre-exposure prophylaxis (PrEP) technologies with and without contraceptive formulation among African American women in the southeastern United States

Public reporting burden of this collection of information is estimated to average 2 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 (0920-1091).

STUDY ID NUMBER (IN HOUSE USE ONLY):_______

Date: ______________

Recruiter___________

Location____________

SECTION 1: TO BE COMPLETED AT TIME OF SCREENING:

We appreciate your interest in the study. I’ll need your name and phone number so we can reach you to schedule your interview and/or to remind you of your scheduled interview. As noted during the screening, we will store your contact information in a secure location, separate from your answers to our questions in the study.

1. What is your preferred name?

_________________________________________________________________________

2. Please provide me with a contact phone number where we can reach you with a reminder.

1. Phone 1 ____________________

3. Is there another number as well?

1. Phone 2 ____________________

4. Is it okay for me to leave a message if you are not available to answer?

Yes [ ] No [ ]

5. Is it okay to text your cell phone if you are not available to answer?

Yes [ ] No [ ]

6. Is it ok to leave a call back number with someone who answers the phone?

Yes [ ] No [ ]

7. Is there an email address that you would like me to use to contact you?

Yes [ ] No [ ]

Email ____________________________

,

8. If known –An interviewer will be in your area the week of [DATE]. If you are eligible, would you be available then for an interview?

Yes [ ] No [ ]

KEEP CONTACT INFORMATION SECURED. IT IS PRIVATE INFORMATION.

SECTION 2: PHONE SCHEDULING - ONCE RESPONDENT IS DETERMINED TO BE ELIGIBLE

Thank you again for your interest in our study. I am calling back about the 2ADoPT research study we are conducting in order to gain input on medical advancements in women’s health. You have been selected to participate in the study if you would still like to do so.

Points to cover:

• The interview takes about 70 minutes.

• The audio-recorded part of the interview will take about 60 minutes and is a like a conversation where someone on our team will serve as the interviewer. The interviewer will ask you questions and you will provide your thoughts, experiences, and feelings related to each of the questions. At the end, we will ask you a short set of questions so that we better understand you. This part of the interview will not be audio recorded and will take about 6 minutes to complete.

• The interview is done virtually. Because you and the person conducting the interview will need to be able to see one another and we have some products to show you, the device you use to connect to the interview will need a camera. What type of device will you be using for the interview?

[ ] Mobile phone

[ ] Tablet such as an iPAD

[ ] Laptop or computer

[ ] Other device (e.g., Kindle, Chromebook) Specify_______________________

• Does your device have a built-in camera?

Yes [ ] No [ ]

• Does your device have a microphone?

Yes [ ] No [ ]

Specify alternative (e.g., earphones with built-in microphone, laptop built-in sound and audio):_________________________________

• Will you need a WIFI on-demand pass?

Yes [ ] No [ ]

• Will you need assistance with the Zoom link, your device’s camera, or WIFI access?

Yes [ ] No [ ]

Specify: _________________________________

• You will receive $40 following the interview. You can choose to receive it as either a gift card or an electronic cash transfer. Specify preference ____________________________________

Do you have any questions?

Attachment 3b_Contact Information

Acceptability and Adoptability of PrEP Technologies (2ADoPT)

OMB # 0920-1091

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