Eligibility Screener

Form Approved

OMB No. 0920-new

Expiration Date: XX/XX/XXXX

Network Epidemiology of Syphilis Transmission (NEST)

Attachment 4

Screener

ELIGIBILITY SCREENER (ES)

Privacy Act Statement:

This information is collected under the authority of the Public Health Service Act, Section 301, "Research and Investigation," (42 U.S.C. 241); and Sections 304, 306 and 308(d) which discuss authority to maintain data and provide assurances of confidentiality for health research and related activities (42 U.S.C. 242 b, k, and m(d)). This information is also being collected in conjunction with the provisions of the Government Paperwork Elimination Act and the Paperwork Reduction Act (PRA). This information will only be used by the Centers for Disease Control and Prevention (CDC) staff to inform development of methodologies for collection of complex sexual network data among men at high risk for syphilis in the 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: OMB-PRA (0920-new).

ES_1. How old are you?

[Refused = 777, Don’t know = 999] __ __ __ years

So, you are [insert age] years old. Is that correct?

No……………………………………………. Loop back to ES_1

Yes……………………………………………

If respondent is < 18 years old, go to to End_1. Else go to ES_2.

END_1. [SAY] Thank you for answering these questions. Unfortunately, you have not been selected to participate in this study. Thank you again for your time.

ES_2. During [insert current year], did you already participate in at least part of this study that we are conducting? It could have been here or at one of our other locations.

Yes	1
No	2
[DO NOT READ THE OPTIONS BELOW ALOUD TO PARTICIPANT]
Refused to answer	77
Don’t know	99

ES_3. What county do you currently live in or what is the zipcode of the neighborhood you currently live in? [Optional: Point to a map of the study site to help prompt a response and confirm correct county].

-------------------------------------------------------------- [text response max length = 250 characters]

ES_4. What was your sex were you assigned at birth, on your original birth certificate? [CHECK ONLY ONE]

Male	1
Female	2
[DO NOT READ THE OPTIONS BELOW ALOUD TO PARTICIPANT]
Refused to answer	77
Don’t know	99

ES_5. How do you describe your gender identity? [CHECK ONLY ONE]

Male	1
Female	2
Male-to-female transgender (MTF)	3
Female-to-male transgender (FTM)	4
Other gender identity	5
[DO NOT READ THE OPTIONS BELOW ALOUD TO PARTICIPANT]
Refused to answer	77
Don’t know	99

[If sex assigned at birth ≠ Male (ES_4 ≠ 1) or gender identity ≠ Male (ES_5 ≠ 1) then skip to END_2].

SAY: The next question is about having sex. Please remember your answers will be kept private. “Having sex” means anal sex (penis in the anus (butt) or oral sex (penis in the mouth)).

ES_6. Have you had anal or oral sex with a man in the past 6 months?

Yes	1
No	2
[DO NOT READ THE OPTIONS BELOW ALOUD TO PARTICIPANT]
Refused to answer	77
Don’t know	99

END_2. If the participant is NOT ELIGIBLE (Do not disclose why the participant is not eligible):

[SAY/DISPLAY]: Thank you for answering these questions. Unfortunately, you have not been selected to participate in this study. Thank you again for your time.

END INTERVIEW

END_3. If the participant IS ELIGIBLE (Do not disclose why the participant is eligible):

[SAY/DISPLAY]: Congratulations! You have been selected to participate in this study. Let me tell you more about it. PROCEED TO CONSENT

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