0920-1161 Patner Survey Screener

Form Approved

OMB No: 0920-1161

Exp. Date: 02/29/2020

Evaluation of Enhancing HIV Prevention Communication and

Mobilization Efforts through Strategic Partnerships

Attachment 3g:

Partner Survey Screener

Public reporting burden of this collection of information is estimated to average 1 hour 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 (0920-1161)

Introduction

We are asking [organizations] to complete a survey about HIV education and awareness practices and policies. To see if you are eligible for this study, we will need to ask you some questions about your organization. If you are eligible and choose to be in the study, all of your answers will be kept private. You can refuse to answer any question or stop at any time.

May we ask you the questions to see if you are a good match for this study?

₁ Yes [CONTINUE]

₂ No [TERMINATE]

1	What would you consider your organization type? (Please select one.) Public Private Non-Profit Trade Association Labor Organization Other [SPECIFY]: ______________ Prefer not to answer
2	What would you consider the primary area of focus for your organization? (Please select one.) Accommodation and Food Services Administrative and Support and Waste Management and Remediation Services Agriculture, Forestry, Fishing and Hunting Arts, Entertainment, and Recreation Barber Shop Beauty Salon Construction Cosmetics, Beauty Supplies, & Perfume Stores, Distributors Cosmetology & Barber Schools Educational Services Finance and Insurance Government (Federal, State, Local, or Tribal) [TERMINATE] Health Care and Social Assistance Information Management of Companies and Enterprises Manufacturing Mining, Quarrying, and Oil and Gas Extraction Nail Salon Other Services (except Public Administration) Professional, Scientific, and Technical Services Public Administration Real Estate and Rental and Leasing Retail Trade Transportation and Warehousing Utilities Wholesale Trade Other [SPECIFY]: ______________ Prefer not to answer
3	Approximately how many employees, both full-time and less than full-time, work for your organization at this worksite? 1-14 Employees [TERMINATE] 15-49 Employees 50-99 Employees 100-249 Employees 250-499 Employees 500-749 Employees 750-999 Employees 1,000 and more Employees Prefer not to answer
4	Does your organization have any other sites including field offices or franchises? Yes [Continue to 4a] No [Skip to 4c] Prefer not to answer [Skip to 4c]
4a	Approximately how many employees, both full-time and less than full-time, work for your organization across all worksites including this worksite? 1-14 Employees [TERMINATE] 15-49 Employees 50-99 Employees 100-249 Employees 250-499 Employees 500-749 Employees 750-999 Employees 1,000 and more Employees Prefer not to answer
4b	Is your organization a multinational firm, with sites outside of the U.S.? Yes [ALL QUESTIONS IN THIS SURVEY WILL ASK ONLY ABOUT YOUR COMPANY'S U.S. OPERATIONS AND MOST OF THE QUESTIONS WILL FOCUS ONLY ON YOUR WORKSITE] No Prefer not to answer
4.c	Is this a female owned organization? Yes No Partially (Please explain: _______________________________) Prefer not to answer
4d	Is this a minority owned organization? Yes No Partially (Please explain: ______________________________) Prefer not to answer
5	We are interested in the racial and ethnic composition of the employees at this worksite. Approximately what percentage of the employees at this worksite are racial or ethnic minorities? None 10% or more More than 10%, but less than or equal to 25% More than 25%, but less than or equal to 50% More than 50%, but less than or equal to 75% More than 75% Prefer not to answer
6	Approximately what percentage of the employees at this worksite are female? None 10% or more More than 10%, but less than or equal to 25% More than 25%, but less than or equal to 50% More than 50%, but less than or equal to 75% More than 75% Prefer not to answer
7	Does this worksite have a department or person responsible for the following:
7a	Employee Assistance Program or EAP? Yes No Prefer not to answer
7b	Occupational Safety & Health? Yes No Prefer not to answer
7c	Are these individuals employees, outside contractors, or both? Employees Outside Contractors Both Prefer not to answer
8	Do any of the employees belong to a union or unions? Yes No Prefer not to answer

If eligible – Invitation:

Thank you for answering all of the questions. You are eligible to take part in the survey. This survey is part of a research study on behalf of the Centers for Disease Control and Prevention (CDC), and we would like to hear your views. This is an important research effort and we appreciate your assistance.

Would you like to participate in this survey?

₁ Yes [CONTINUE]

₂ No [INELIGIBLE]

If ineligible – Closing:

Thank you for answering all of the questions. You are not eligible to be in this study because you did not meet our eligibility criteria. These reasons were decided on earlier by the researchers. We value your interest in this research study. Thank you for being willing to help us.