Verificatgion of Eligibility

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 # 3b

Eligibility Verification

Public reporting burden of this collection of information is estimated to average 5 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)

S. Verification of eligibility

S1. Are you able to read and understand English?

☐ Yes [eligible] ☐ No

S2. What is your current age? _____ [18+ eligible]

S3. Are you Hispanic, Latino, or Spanish origin?

☐ Yes ☐ No

S4. What best describes your Hispanic or Latino ancestry?

☐ Mexican, Mexican American, Chicano ☐ Puerto Rican ☐ Cuban

☐ Other Hispanic/Latino or Spanish origin, specify: __________

S5. What is your race? You may choose more than one [select all that apply].

☐ American Indian or Alaska Native ☐ Asian ☐ Black or African American

☐ Native Hawaiian or Other Pacific Islander ☐ White

S6. What is the zip code of your current place of residence? __ __ __ __ __ [eligible with acceptable site MSA zips]

S7. How do you describe your gender identity?

☐ Male [eligible] ☐ Female ☐ Male-to-female transgender (MTF) ☐ Female-to-male transgender (FTM)

☐ Other gender identity, specify: ____________________

S8. What sex is on your original birth certificate?

☐ Male [eligible] ☐ Female

S9. What was your most recent HIV test result?

☐ HIV Negative [eligible] ☐ HIV Positive ☐ Never tested ☐ Tested but didn’t receive results

☐ Indeterminate

S11. In the past 12 months, that is since [mm/yyyy], have you had sex with a man?

☐ Yes [eligible] ☐ No

S12. In the past 3 months, that is since [mm/yyyy], have you had anal sex with a man without using a condom?

☐ Yes [eligible] ☐ No

S13. [If HIV-negative or Never Tested…] In the past 6 months, that is since [mm/yyyy], have you discussed PrEP, or pre-exposure prophylaxis – a daily pill you can take to prevent HIV -- with a provider or counselor?

☐ Yes ☐ No

S14. In the past 6 months, have you been offered PrEP by a doctor or nurse?

☐ Yes  [PHASE 1, n=120] ☐ No  [PHASE 2, n=160-180]

S15. [If yes] Did you accept or refuse their offer of PrEP?

☐ Accept ☐ Refuse  [PHASE 1.A, n=60]

S16. [If Accept] Did a doctor or nurse give you a prescription for PrEP?

☐ Yes  [PHASE 1.B, n=60] ☐ No

S17. [If Yes] Did you fill the prescription for PrEP?

☐ Yes ☐ No [end screener]

S18. [If Yes] How long ago did you first fill the prescription for PrEP?

__ 7 days or less

__ 1-2 weeks

__ 3-4 weeks

__ 1-3 months

__ 4-6 months

__ 7-12 months

__ 1-2 years

__ >2 years

S19. [If Yes] In total, on how many days did you take the daily PrEP pill?

__ 0

__ 1

__ 2

__ 3

__ 4

__ 5

__ 6

__ 7 [<=7, eligible unsuccessful uptake]

__ 8 [8+, ineligible]

__ 9

__ 10

__ More than 10

S20. Are you still taking the daily PrEP pill?

☐ Yes [Ineligible] ☐ No [Algorithm to determine unsuccessful uptake] n=60