Eligibility screening form

Injection Drug Use Surveillance Project

Att 3 Eligibility screening form

OMB: 0920-1325

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Form Approved
OMB No. 0920-xxxx
Expiration Date: XX/XX/XXXX

Injection Drug Use Surveillance Project

Attachment # 3
Eligibility Screening Form

Privacy Act Statement:
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 assurances of confidentiality 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) and staff at the University of Washington to develop
a surveillance system to monitor drug use risk and prevention behaviors and the infectious
disease consequences of high-risk drug use in syringe services programs (SSPs) in rural and
urban areas the US.

Public reporting burden of this collection of information is estimated to average 5 minutes
to screen and assess for eligibility in order to partake in survey. 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)

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IDU Surveillance Questionnaire
Please complete the survey below.

“Public reporting burden of this collection of information is estimated to average 30 minutes
per survey, including the time for reviewing instructions, administering questions and
entering responses. 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).”
IE1. INTERVIEWER: Please enter today's date
(mm/dd/yyyy):

02/19/2020 4:18pm

__________________________________

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IE2. INTERVIEWER: Please enter the current time
(hh:mm) using a 24-hour clock. Example: 1:30pm
should be entered as 13:30.

02/19/2020 4:18pm

__________________________________

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IE3. INTERVIEWER: Interviewer ID:

02/19/2020 4:18pm

__________________________________

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IE4. INTERVIEWER: City (SSP location):

02/19/2020 4:18pm

[CITY 1]
[CITY 2]
[CITY 3]

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IE5. INTERVIEWER: Participant ID:

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__________________________________
(Must be 4 digits)

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IE6. Please copy the following unique Survey ID in
the text box:
[SSPCITY:value] [PID:value]

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__________________________________
(Do not add any spaces.)

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IE7. INTERVIEWER: Is [SURID] correct?

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No
Yes

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IE8. INTERVIEWER: Field Site ID:

02/19/2020 4:18pm

__________________________________

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IE9. INTERVIEWER: Was the respondent selected from
the syringe exchange program?

02/19/2020 4:18pm

No
Yes

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READ: "I'd like to thank you again for your interest in this health survey. Remember that all information you give me
will be kept private and I will not ask for your name. Most people have never been in an interview like this one. Some
questions may sound awkward, but I need to read them as worded so everyone in the study is asked the same
questions. First, I will ask you a few questions about yourself and then the computer will determine if you have been
selected to participate in the health survey."

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HIDDEN, AUTOMATIC CALCULATION: Start time of
eligibility screener

02/19/2020 4:18pm

__________________________________

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ES1a. What is your month and year of birth?
[INTERVIEWER: FIRST ENTER MONTH OF BIRTH]

02/19/2020 4:18pm

January
February
March
April
May
June
July
August
September
October
November
December
Don't Know
Refuse to Answer

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ES1b. [INTERVIEWER: ENTER YEAR OF BIRTH]

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__________________________________
(IF DON'T KNOW OR REFUSED, LEAVE BLANK)

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DOB -- HIDDEN CALCULATION: Create concatenated date
of birth variable: DOB_M, “/”, “15”,
“/”, DOB_Y. Impute the 15th day of the month to
create a date variable that we can use in
calculations.

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AGE1 -- HIDDEN CALCULATION: Calculate age from date
of birth (DOB)

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__________________________________

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AGE2 -- HIDDEN CALCULATION: Calculate age from date
of birth (DOB), then subtract 1 year

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__________________________________

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ES1c. So, you are [AGE1] years old. Is that correct?

02/19/2020 4:18pm

No
Yes

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ES1d. So, you are [AGE2] years old. Is that correct?

02/19/2020 4:18pm

No
Yes

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AGE -- HIDDEN CALCULATION: Calculated age, confirmed
by R

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__________________________________

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ES2. Do you consider yourself to be Hispanic,
Latino/a, or Spanish origin?

02/19/2020 4:18pm

No
Yes
Don't Know
Refuse to Answer
(If necessary, say "Just tell me Yes or No.")

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[GIVE RESPONDENT FLASHCARD A.]
ES3. Which racial group or groups do you consider
yourself to be in? You may choose more than one
option.
[READ choices. CHECK ALL that apply.]

02/19/2020 4:18pm

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Don't Know
Refuse to Answer
Not Applicable

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[GIVE RESPONDENT FLASHCARD B.]
ES4. What best describes your gender? You may choose
more than one option.
[READ choices. CHECK ALL that apply.]

02/19/2020 4:18pm

Man
Woman
Genderqueer/non-binary
Trans man
Trans woman
Other gender not listed
Don't Know
Refuse to Answer

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ES4spec. INTERVIEWER: What best describes your
gender?

02/19/2020 4:18pm

__________________________________

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ES5. What was your sex at birth?
[DO NOT READ choices.]

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Male
Female
Intersex/ambiguous
Don't Know
Refuse to Answer

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ES6. How well do you speak English?
[READ choices.]

02/19/2020 4:18pm

Very well
Well
Not well
Not at all
Don't Know
Refuse to Answer

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READ: "Now I am going to ask you about experiences you may have had with injecting drugs. This means injecting
drugs yourself or having someone who is not a healthcare provider inject you with a needle, either in your vein,
under the skin, or in the muscle.
Please only think about drugs you may have gotten without a prescription from your doctor or other healthcare
provider, like heroin, methamphetamine, and drugs like Oxycontin. Please also think about drugs that were
prescribed to you, but you used them in ways other than instructed by your doctor or healthcare provider."

02/19/2020 4:18pm

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ES7. Have you ever in your life injected any drugs?

02/19/2020 4:18pm

No
Yes
Don't Know
Refuse to Answer

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ES8a. When was the last time you injected any drug?
That is, how many days or months or years ago did
you last inject?
[INTERVIEWER: If today, enter "0"]

02/19/2020 4:18pm

__________________________________
(IF DON'T KNOW OR REFUSED, LEAVE BLANK)

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ES8b. [INTERVIEWER: Was this days or months or
years?]

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Days
Months
Years

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E_INJ6 -- HIDDEN CALCULATION: injected in last 6
months

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__________________________________

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ES9. In the past 6 months, which drugs have you injected? Please say "yes" or "no" to each
drug I mention. [READ choices. CHECK ALL that apply.]
No

Yes

Don't Know

Speedball, which is heroin and
cocaine together
Goofball, which is heroin and
methamphetamine together
Fentanyl, by itself or in
combination with other drugs
Heroin, by itself
Methamphetamine, by itself,
also known as meth or speed
Powder cocaine, by itself
Crack cocaine, by itself
Painkillers, such as Oxycontin,
Dilaudid, or Percocet
Benzodiazepines or other
downers, such as Valium, Xanax,
or Klonopin

02/19/2020 4:18pm

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Refuse to Answer

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ES10. In the past 6 months, have you injected
methadone?

02/19/2020 4:18pm

No
Yes
Don't Know
Refuse to Answer

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ES11. In the past 6 months, have you injected
buprenorphine, also known as Suboxone or Subutex?

02/19/2020 4:18pm

No
Yes
Don't Know
Refuse to Answer

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ES12. Are there any other drugs you have injected in
the past 6 months?

02/19/2020 4:18pm

No
Yes
Don't Know
Refuse to Answer

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ES12spec. INTERVIEWER: Specify other injection drug.

02/19/2020 4:18pm

__________________________________

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ES13. Which drug do you inject most often?
[DO NOT READ choices.]

02/19/2020 4:18pm

Speedball, which is heroin and cocaine together
Goofball, which is heroin and methamphetamine
together
Fentanyl, by itself or in combination with other
drugs
Heroin, by itself
Methamphetamine, by itself, also known as meth or
speed
Powder cocaine, by itself
Crack cocaine, by itself
Painkillers, such as Oxycontin, Dilaudid, or
Percocet
Benzodiazepines or other downers, such as Valium,
Xanax, or Klonopin
Methadone
Buprenorphine, also known as Suboxone or Subutex
Something else
Don't Know
Refuse to Answer

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ES13spec. INTERVIEWER: Specify other injection drug.

02/19/2020 4:18pm

__________________________________

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READ: "Now I am going to ask you about experiences you may have had with drugs that you did not inject. This
includes times that you may have smoked, snorted, inhaled, or ingested drugs.
Please only think about drugs you may have gotten without a prescription from your doctor or other medical
provider, like heroin, methamphetamine, and drugs like Oxycontin. Please also think about drugs that were
prescribed to you but you used them in ways other than instructed by your doctor or healthcare provider."

02/19/2020 4:18pm

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ES14. Have you ever in your life used any drugs that
you did not inject?

02/19/2020 4:18pm

No
Yes
Don't Know
Refuse to Answer

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ES15a. When was the last time you used any drug that
you did not inject? That is, how many days or months
or years ago did you last use drugs? [INTERVIEWER:
If today, enter "0"]

02/19/2020 4:18pm

__________________________________
(IF DON'T KNOW OR REFUSED, LEAVE BLANK)

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ES15b. [INTERVIEWER: Was this days or months or
years?]

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Days
Months
Years

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E_DRG6 -- HIDDEN CALCULATION: used drug in last 6
months

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__________________________________

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ES16. In the past 6 months, which drugs did you use that did NOT inject? Please say "yes" or
"no" to each drug I mention.
No

Yes

Don't Know

Marijuana
Methamphetamine, also known
as meth or speed
Crack cocaine
Powder cocaine
Benzodiazepines or other
downers, such as Valium, Xanax,
or Percocet
Painkillers, such as Oxycontin,
Dilaudid, or Percocet
X or ecstasy (MDMA)
Heroin
Fentanyl, by itself or in
combination with other drugs
Adderall, Ritalin, or other
commonly prescribed stimulants

02/19/2020 4:18pm

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Refuse to Answer

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ES17. In the past 6 months, have you used methadone
that was not prescribed or not taken as prescribed?

02/19/2020 4:18pm

No
Yes
Don't Know
Refuse to Answer

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ES18. In the past 6 months, have you used
buprenorphine, also known as Suboxone or Subutex,
that was not prescribed or not taken as prescribed?

02/19/2020 4:18pm

No
Yes
Don't Know
Refuse to Answer

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ES19. Are there any other drugs you have used and did
not inject in the past 6 months?

02/19/2020 4:18pm

No
Yes
Don't Know
Refuse to Answer

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ES19spec. INTERVIEWER: Specify other non-injection
drug.

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__________________________________

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ES20. INTERVIEWER: Is this person alert and capable
of completing the survey in English?

02/19/2020 4:18pm

No
Yes

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ES21. INTERVIEWER: Specify reason person not able to
complete the interview:

Not able to understand or give permission
Cannot speak and understand English

[CHECK ALL that apply.]

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ES22. INTERVIEWER: Has this person participated in
this study before?

02/19/2020 4:18pm

No
Yes

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ES23. INTERVIEWER: Did your field supervisor tell you
that this person cannot complete the survey for some
other reason?

02/19/2020 4:18pm

No
Yes

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READ: "We've finished the first series of questions. Now the computer will determine whether you've been selected
to participate in the survey."

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Hidden, calculated variable: EL_IDU = IF((AGE>17 &
CAPABLE=1 & E_PART=0 & SUPERV=0 & (E_INJ6=1 OR
(E_DRG6=1 AND E_DRGEL=1)),1,0)

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If R NOT eligible for cycle, READ: "Unfortunately, the computer has not selected you to participate in the health
survey. Thank you for your time." Then go to STOP.

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ES24. INTERVIEWER: This participant was not selected
for this health survey. Please click stop to end
survey.

02/19/2020 4:18pm

Stop

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If R eligible for cycle, READ: "Congratulations! The computer has selected you to participate in the health survey. Let
me tell you about it."
[INTERVIEWER: Proceed with the permission process.]

02/19/2020 4:18pm

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CN1. Do you agree to take part in the survey?

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No
Yes

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CN2. Do you agree to HIV counseling and testing?

02/19/2020 4:18pm

No
Yes

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CN3. Do you agree to hepatitis C testing?

02/19/2020 4:18pm

No
Yes

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CN4. Do you agree to let us store some of your blood
for future testing?

02/19/2020 4:18pm

No
Yes

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HIDDEN, AUTOMATIC: End time of eligibility screener

02/19/2020 4:18pm

__________________________________

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File Typeapplication/pdf
AuthorPtomey, Natasha (CDC/OID/NCHHSTP) (CTR)
File Modified2020-04-21
File Created2020-02-19

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