Form 0920- Participant Recruitment Scripts & Screener Questions

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Red Carpet Entry (RCE) Program Implementation Project

Attachment # 3j

Participant 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-New)

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Red Carpet Entry

Participant Recruitment Scripts & Screener Questions

Instructions to the RCE Concierge: All patients who are newly diagnosed, or who are not currently receiving care for their HIV can enter into care via RCE. However, only certain patients are eligible for the RCE study. Use the screener below to identify (1) patients who are eligible to enter care through RCE and (2) those who are eligible for the study.

Part 1: Introduction & Screening – When Participant is Introduced to the RCE Concierge

Hi, I’m [NAME], and I’m the Red Carpet Entry Concierge at [CLINIC NAME]. We’re so happy to welcome you to our clinic today! As the Concierge, it’s my job to escort you throughout your first RCE Visit, make sure you feel comfortable, introduce you to the members of your care team, and answer any questions you might have. Before we get started, I’d like to ask you a few questions to make sure that Red Carpet Entry is right for you.

May I proceed?

No è [Thank respondent and end conversation.]

Yes è CONTINUE

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-New)

1. What language are you most comfortable speaking and writing?

_____

English è CONTINUE Spanish è CONTINUE All Other Languages è TERMINATE FOR STUDY CONTINUE FOR RCE CLINICAL CARE

2. How old are you?

_____

<18 è CONTINUE 18+ è SKIP to Q4

3. Are you an emancipated minor?

Yes		è CONTINUE
No		è TERMINATE FOR STUDY CONTINUE FOR RCE CLINICAL CARE

4. Have you ever tested positive for HIV?

Yes		è CONTINUE
No		è TERMINATE FOR STUDY & RCE CLINICAL CARE

5. When did you test positive?

_DD/MM/YY__

≤ 12 months è CONTINUE [Patient Qualifies as Newly Diagnosed] > 12 months ago è CONTINUE

6. Have you ever received care by a doctor for your HIV?

Yes		è CONTINUE
No		è SKIP TO END [Patient Qualifies as New to Care]

7. When was the last time you saw your HIV doctor?

_MM/YY__

< 12 months è TERMINATE FOR STUDY CONTINUE FOR RCE CLINICAL CARE > 12 months ago è CONTINUE [Patient Qualifies as Out of Care]

[If Eligible] Great! It looks like you’re eligible for Red Carpet Entry. If you would like to continue, we can schedule your first visit with us. [Allow time for the client to ask questions about what the first visit entails, then schedule visit].

[If Not Eligible for RCE] Unfortunately, it doesn’t seem like Red Carpet Entry is a good option for you at this time. Let’s talk about other ways our clinic might be able to support you in your medical care.

Part 2: Consenting for Eligible Patients

2a. Towards the end of the RCE Concierge Introduction

Before I introduce you to [name of next person patient will interact with] I wanted to let you know that we are doing a study about how [CLINIC NAME] is running Red Carpet Entry. Through this study, we hope to learn more about the best ways to get people connected to medical care as quickly and stress-free as possible. You do not have to agree to be a part of this evaluation to receive medical care through Red Carpet Entry at our clinic. Also, I know this can be an overwhelming time, so you do not need to decide anything right now. We will talk about it again at the end of your visit today.

2b. When Participant is wrapping up their RCE Visit

Before you leave today, I wanted to talk to you again about the evaluation of Red Carpet Entry at [CLINIC NAME], as I mentioned earlier today. The purpose of this evaluation is to learn more about how RCE is being implemented in [CLINIC NAME]. What we learn will help the Centers for Disease Control and Prevention (CDC) make Red Carpet Entry a better experience for patients just like you all across the country and help us connect them to their care teams more quickly and as stress-free as possible. If you choose to participate, we will collect the following information from your electronic health record: medical care appointment dates and attendance, confirmation of your HIV diagnosis, and information such as your age, sex, and race/ethnicity. You do not have to complete any surveys or get any additional bloodwork done. These data will not have your name, or any other identifying information attached to it and will stay confidential. As a thank you, you will receive a $25 gift card before you leave today. You may choose to stop participation at any time for any reason. As a reminder, you do NOT have to participate in this evaluation to receive medical care through Red Carpet Entry at our clinic.

Are you interested in participating?

Yes è [Review consent and HIPPA forms with client; answer questions and obtain client signatures. Provide the client with a $25 gift card and finish the RCE visit wrap-up.] . Record date and time of client consent in the access database. Provide the client with an unsigned copy of the consent form and HIPAA authorization form for their records if requested.

No è [Thank respondent and finish RCE Visit wrap-up.]