Registration Contact information
Form Approved
OMB No. 0920-New
Expiration Date: XX/XX/XXXX
Web-based Approaches to reach black or African American and Hispanic/Latino MSM for HIV Testing and Prevention Services
Attachment 3b
Registration Contact information
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)
Based on your answers, you qualify to enroll in our study. Please provide the following information (first and last name, phone number, email address and contact preference) so we may contact you to schedule your participation in the study. The information you provide here will be kept separate from other information you provide to us in the course of this study, and access to any contact information you provide will be limited to key study staff.
Please take a moment to review your answers before submitting them. Please make sure that your contact information is accurate, as inaccurate contact information may prevent us from being able to contact you.
What is the current, 10-digit phone number for the mobile phone you plan to use during this study? This should be a device that you are able to receive text messages on with important information such as reminders to complete more health surveys.
Phone number: (__ __ __) -- __ __ __ -- __ __ __ __
[PHNNUMB]
[using form validation, if provided phone number does not have 10 digits, reject entry and prompt user correction with: “You must provide a valid, 10-digit phone number to participate in our study.” If three incorrect attempts, then skip to End 1.]
[ACTION: Code sent to phone number provided]
Now, please check your telephone. You should have received a text message from us with a code. What is the code? _____________
[PHNCODE]
[If correct, display “Thank you for entering the correct code” and proceed to next question. If not correct, display “Sorry, that is an incorrect code. Please re-enter the code to proceed.” If three incorrect attempts, then skip to End 1]
What is your current email address? __________________________________
[EMAIL]
[using form validation, if provided email address does not conform to ___@___.___ format, reject entry and prompt user correction with: “You must provide a valid email address to participate in our study.”]
[ACTION: Code sent to email address provided]
Now, please check your email account. You should have received an email from us with a code. What is the code? _____________
[EMAILCODE]
[If correct, display “Thank you for entering the correct code” and proceed to next question. If not correct, display “Sorry, that is an incorrect code. Please re-enter the code to proceed.” If three incorrect attempts, then skip to End 1]
Please provide us with a shipping address so we can send you rapid HIV home test kits during the study. The package will arrive in a plain shipping box. You may choose to receive packages at home, at a family member’s address, or a friend’s address. However, we cannot ship to a P.O. Box. If you cannot provide a shipping address you cannot participate in our study.
Enter shipping address:*
Address 1: ____________________ [ADDRESS1]
Address 2: ____________________ [ADDRESS2]
City: ____________________ [CITY]
State: ____________________ [STATE]
ZIP Code: ____________________ [ZIP]
If not answered, display “Please enter a valid shipping address to proceed.” and loop back to enter the shipping address.
If study staff contacts you regarding participation in the study, how would you most prefer to be contacted? Please select one.
Phone Call
Text Message
No preference
[CONTACT]
If study staff contacts you regarding participation in the study, they will first attempt to contact you by the contact method you prefer. If unable to make contact by the preferred method, study staff will attempt to make contact by other means.
During this study, we will not connect your name with any survey responses you provide Please provide us with your name, or if you prefer, a nickname, alias or name of your choice that we can use throughout the study to communicate with you. This name will also be displayed on the package mailed to you as part of this study. You will need to know by the name on the package that it is for you.
What is your full name? Please include a first and last name _______________________
[using form validation, if provided name has 0 characters, reject entry and prompt user correction with: “You must provide a full name to participate in our study.”]
End 1. If the participant does not provide the required information:
Thank you for your interest in this health study. Unfortunately, you were not selected to participate any further. Any contact information you provided us above will be destroyed.
If you want to learn more about HIV, where to get more information, or where to get tested in your area, please click on the following links:
Information about HIV
HIV Testing Resources
CDC HIV Testing Locator (https://gettested.cdc.gov/)
CDC HIV Testing Information Page (https://www.cdc.gov/hiv/testing/)
AIDS.gov HIV Testing Locator (https://www.aids.gov/hiv-aids-basics/prevention/hiv-testing/hiv-testlocations/)
AIDSvu HIV Testing Locator (https://aidsvu.org/locators/testing-sites/)
PrEP Resources
Centers for Disease Control PrEP Resources (https://www.cdc.gov/actagainstaids/campaigns/starttalking/materials/prepresources.html)
The Fenway Institute: What is PrEP? (http://thefenwayinstitute.org/prepinfo/)
PrEP Locator (https://preplocator.org/)
AIDS.gov PrEP Information Page (https://www.aids.gov/hiv-aids-basics/prevention/reduce-yourrisk/pre-exposure-prophylaxis/)
If you have any questions or comments, you may contact the Principal Investigator, Dr. Patrick Sullivan of Emory University, at (404) 727-2038 or [email protected].
Otherwise, you can close your browser window. Thank you for your time.
End survey.
End 2. If the participant provides the required information:
Congratulations! You are registered to participate in this health study.
The next step is to complete a baseline health survey. You will be contacted and given instructions with how to complete the baseline survey. Please note that this can take up to two weeks. At any time, you may contact the study coordinator at [email protected] with questions.
Version : X.X OMB # XXXX-XXXX Expiration date: X/XX/XXXX
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Weiss, Kevin |
| File Modified | 0000-00-00 |
| File Created | 2021-01-14 |