PrEP Project Contact Form

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Understanding Decisions and Barriers about PrEP Use and Uptake Among Men Who Have Sex With Men

Attachment #3f

Contact Form

Public reporting burden of this collection of information is estimated to average 1 minute 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)

ID (IN HOUSE USE ONLY) :_______

Date: ______________

Recruiter___________

Location____________

PrEP Project Contact Form

SECTION 1: TO BE COMPLETED AT TIME OF SCREENING:

We appreciate your interest in the study. I’m going to forward this information to the recruiting coordinator to determine if you are eligible for this study. If you are eligible, we will get back to you with more details. I’ll need your name and phone number so we can reach you if you qualify.

1. What is your preferred name?

__________________________

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

Phone 1 ____________________

1. Is there another number as well? Phone 2 ____________________

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

Yes [ ] No [ ]

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

Yes [ ] No [ ]

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

Yes [ ] No [ ]

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

1. YES Specify ____________________________

2. NO

4. What city/area are you calling from? ______________________________

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 research study we are conducting in order to better understand attitudes and behaviors in HIV prevention.] You have been selected to participate in the study, if you would still like to.

Are you still available on (DATES) (TIMES) to participate in a focus group? Yes [ ] No [ ] The focus group takes about two hours. The focus group will take place at [LOCATION] on [DATE] You will receive $75 cash at the end of the focus group session.

(IF UNABLE TO MAKE ANY OF THE TIMES/DATES, EXPLAIN THAT THEY MIGHT QUALIFY FOR AN IN-PERSON INTERVIEW, AND ASK QUESTION B) Would you be willing to participate in an in-person interview at a time and a place convenient to you? Yes [ ] No [ ] The interview takes about 90 minutes. The interview needs to be in person. We’ll have an interviewer in [AREA] at [LOCATION] on [DATES] You will receive $60 cash following the interview.

• Your participation is completely voluntary and you do not have to answer any questions you do not feel comfortable answering.

• Participation in this research will in no way impact any care or services you may be receiving or are entitled to receive.

• Do you have any questions?