Contact information

Form Approved

OMB No. 0920-1091

Exp. Date 08/31/2021

Attachment 3b Contact Information Form

Assessing the acceptability and adoptability of HIV-1 pre-exposure prophylaxis (PrEP) technologies with and without contraceptive formulation among African American women in the southeastern United States

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: PRA (0920-1091).

 

SECTION 1: TO BE COMPLETED AT TIME OF SCREENING:

STUDY ID NUMBER (IN HOUSE USE ONLY):_______

Date: ______________

Recruiter___________

Location____________

We appreciate your interest in the study. I’ll need your name and phone number so we can reach you to schedule your interview and/or to remind you of your scheduled interview. As noted during the screening, we will store your contact information in a secure location, separate from your answers to our questions in the study.

1. What is your preferred name?

__________________________

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

Phone 1 ____________________

4. Is there another number as well?

Phone 2 ____________________

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

Yes [ ] No [ ]

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

Yes [ ] No [ ]

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

Yes [ ] No [ ]

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

Yes [ ] SPECIFY ____________________________

No [ ]

9. IF KNOWN –An interviewer will be in your area the week of [DATE]. If you are eligible, would you be available then for an interview?

Yes [ ] No [ ]

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 2ADoPT research study we are conducting in order to gain input on medical advancements in women’s health. You have been selected to participate in the study, if you would still like to.

POINTS TO COVER:

• The interview takes about 70 minutes.

• An interview is a like a conversation where someone on our team will serve as the interviewer. The interviewer will ask you questions and you will provide your thoughts, experiences, and feelings related to each of the questions. At the end, we will ask you a short set of questions so that we better understand you.

• The interview needs to be in person. We’ll have an interviewer in

• [AREA] at

• [LOCATION] on

• [DATES]

• You will receive $40 cash following the interview.

Do you have any questions?

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