Form 0920-1091 Deep South Client Screener (English)

Attachment XX.

Deep South Client Screener - English

Form Approved

OMB No.: 0920-1091

Expiration Date: 09/30/2021

Attachment 3a Client Screener

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)

ID:_________________

Date: ______________

Client/CBO:________

Race:___________

HIV Status: Pos / Neg

Recruiter:___________

Location:____________

Deep South Screener

Client

Version 5.0

7/19/2018

1. How old are you? _________

1. 13-17

2. 18-21

3. 22-24

4. 25+

2. Why do you think you qualify for this study?

3. Where did you learn about this study?

1. Friend/Flyer/Online Ad

2. Other ________________

4. 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

I don’t know the answer 5

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

Male ………………………….. 1

Female ………………………….. 2

Refused…………………………………………………………………………… 3

Don’t know……………………………………………………………… ………. 4

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

Male . 1

Female . 2

Transgender……… . 3

None of these……… . 4

6. Just to confirm, you were assigned {_FILL based on Question_5} at birth and now describe yourself as {FILL based on Question 6}. Is that correct?

Yes . 1

No . 2

Refused…………………………………………………………………… ……… 3

Don’t know……………………………………………………………… ……….

8. Do you consider yourself to be of Hispanic, Latino/a, or Spanish origin? (Interviewer, code one)

[ ] No
[ ] Yes

[ ] Refused to answer

[ ] Don’t Know

9. Which racial group or groups do you consider yourself to be in? You may choose more than one option. [READ CHOICES. CODE ALL THAT APPLY.]

1. ____American Indian or Alaska Native

2. ____Asian

3. ____Black or African American

4. ____Native Hawaiian or Other Pacific Islander

5. ____White

6. ____Refused to answer

7. ____Don’t know

10. In what city/county do you live? ____________________________

11. What is your HIV status?

1. ____ HIV positive

2. ____ HIV negative

3. ____ Don’t know/REFUSED TO ANSWER

12. How many times have you visited [CBO] or used their services in the past 12 months? _____

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