Staff and Stakeholder Screener

Attachment 2b: SSP Staff Screening Form

RURAL EXPERIENCE AND ACCESS STUDY

Staff/Stakeholder Screening Form

Form Approved

OMB No: 0920-1091

Exp. Date: 09/30/2021

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 privacy 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 evaluate Syringe Service Programs’ (SSP) User Experiences.

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 (0920-1091)

Date: ___________

Study identification number: _________

Screener Three Digit Initials: ________

Thank you for calling. My name is ________ and let me tell you a little about the study. I am part of a study team that wants to learn more about syringe service programs, HIV, Hepatitis B and C, injection drug use, and topics that will help us understand what services [name SSP] offers as well as what services the clients/participants need. The study consists of a face-to-face interview that should take about an hour of your time in a place convenient to you. Before we schedule the interview, I have a few questions to see if you qualify for the study. You do not have to answer any questions you do not want to answer. You may stop at any time. Just let me know you no longer wish to answer any questions, and I will stop. If you do not qualify for this study, the information you have given me will be destroyed. If you are eligible and you decide to participate, the answers that you give will be used in the study. Your answers will be identified by a study identification number, not your name. Do you have any questions before we proceed? Do I have your permission to proceed?

[SCREENER DIRECTIONS: PLEASE DO NOT READ THE OPTIONS IN ALL CAPS; THESE ARE IN CASE THE PARTICIPANT PROVIDES AN ANSWER NOT SPELLED OUT IN THE OPTIONS YOU ARE TO READ. ELIGIBILITY CRITERIA ARE: 18 YEARS AND OLDER, AND A PROFESSIONAL/VOLUNTEER RELATIONSHIP TO THE SSP]

1. How old are you?

2. Do you work for, or with [name SSP] to address addiction in your community?

☐ Yes

☐ No

[IF YES] What is your relationship to [name SSP]: __________?

3. What sex were you assigned at birth, on your original birth certificate?

Male ………………………….. 1

Female ………………………….. 2

DON’T KNOW . 3

REFUSED TO ANSWER . 4

4. Do you currently describe yourself as male, female, or transgender?

Male . 1

Female . 2

Transgender . 3

NONE OF THESE . 4

REFUSED TO ANSWER . 5

5. Just to confirm, you were assigned {_FILL based on first question__} at birth and now describe yourself as {FILL based on 2nd question}. Is that correct?

☐ Yes

☐ No

☐ REFUSED TO ANSWER

☐ DON’T KNOW

6. Which of the following best represents how you think of yourself:

Gay (lesbian or gay) 1

Straight, this is not gay (or lesbian or gay) 2

Bisexual 3

SOMETHING ELSE 4

DON’T KNOW 5

7. Do you consider yourself to be Hispanic or Latino/a?

☐ Yes

☐ No

☐ Refused to answer

8. Which racial group, or groups, do you consider yourself to be? [READ CHOICES. CODE ALL THAT APPLY.]

☐ American Indian or Alaska Native

☐ Asian

☐ Black or African American

☐ Native Hawaiian or Other Pacific Islander

☐ White