Form Approved
OMB No: 0920-1169
Exp. Date: 03/31/2020
Development of CDC’s Let’s Stop HIV Together Social Marketing Campaign for Consumers
Attachment 3a: Screening Instrument for In-depth Interviews and Focus Groups
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: OMB-PRA (0920-1169).
Introduction
Hello, my name is _______________ and I’m from (name of company). We are calling on behalf of RTI International, a non-profit research organization, and the Centers for Disease Control and Prevention.
We are not selling any product. We are calling to invite individuals in your area to join in discussions as part of a study about HIV. Your opinions are important to us and will contribute to the CDC’s efforts supporting the national Ending the HIV Epidemic plan.
If you are eligible and choose to participate in the interview/focus group, you will receive $50 (interview)/$75 (focus group) as a token of our appreciation for participating in this important study.
To see if you are eligible for this study, we need to ask you some personal questions. There will be some explicit questions about your sexual behavior and HIV. It is your choice to answer these questions. Your answers will be kept private. You can refuse to answer a question or stop at any time.
All of your comments will be kept private. If you are not eligible and/or choose not to be part of the study, all responses you give me today will be destroyed and you will not be contacted again.
My questions will only take a few minutes. May I ask you the questions now?
Yes...................1 Continue
No....................2 Thank and End
Procedures for Recording and Limiting Information
Only record information for the questions in the screener. If an informant reveals additional personal information, thank them for being helpful, but guide them back to the screener questions – “That is interesting to learn, but can I ask you about…”
A. Have you ever participated in a focus group or interview session before?
Yes |
1 |
|
No |
2 |
[SKIP TO Q1] |
B. What was/were the topics discussed?
|
|
[IF PARTICPATED IN A FOCUS GROUP OR INTERVIEWABOUT HIV/AIDS IN THE PAST 6 MONTHS, INELIGIBLE] |
C. When was the last time you attended a focus group or interview session?
Less than 6 months ago |
1 |
[IF PARTICPATED IN A FOCUS GROUP OR INTERVIEWABOUT HIV/AIDS IN THE PAST 6 MONTHS, INELIGIBLE] |
More than 6 months ago |
2 |
|
Background Information
1. How old are you?
Age__________ [INELIGIBLE IF UNDER 18 OR OVER 64]
8 Don’t know [INELIGIBLE]
9 Prefer not to answer [INELIGIBLE]
2. What is your current gender identity? (Select ALL that apply)
1 Male
2 Female
3 Transgender Male/Transman/FTM
4 Transgender Female/Transwoman/MTF
5 Genderqueer
6 Another category [Specify: ]
9 Prefer not to answer [INELIGIBLE]
3. What sex were you assigned at birth? (Select one)
1 Male
2 Female
3 Prefer not to answer [INELIGIBLE]
4. Which do you consider yourself to be?
1 Gay or homosexual
2 Bisexual
3 Straight or heterosexual
4 Queer
5 Pansexual
4 Another category [Specify: ]
5 None of the above/Unsure
9 Prefer not to answer [INELIGIBLE]
5. Are you of Hispanic or Latino origin?
1 Yes
2 No
9 Prefer not to answer [INELIGIBLE]
6. Please indicate your race. Are you? You may select one or more races.
1 White
2 Black or African American
3 Asian
4 Native Hawaiian or Other Pacific Islander
5 American Indian or Alaskan Native
9 Prefer not to answer [INELIGIBLE]
7. What language are you most comfortable using with your family and friends?
1 English
2 Spanish
3 English and Spanish equally
4 Other [Specify: _______________________________________________________]
9 Prefer not to answer
8. Have you ever been tested for HIV? An HIV test checks whether someone has the virus that causes AIDS.
1 Yes
2 No [SKIP TO S10]
9 Prefer not to answer [INELIGIBLE]
9. The next question is about the result of your HIV test. What was the result of your most recent HIV test?
1 I tested positive for HIV.
2 I tested negative for HIV.
3 My results were unclear.
8 I never got my results/Don’t know.
9 Prefer not to answer [INELIGIBLE]
9(a) If HIV positive:
When did you test positive for HIV [insert month and year]?
9(b). If HIV negative:
In the past 2 years, that is, since [insert calculated month and year], how many times have you been tested for HIV?
0 0
1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9 or more
10 Prefer not to answer
10. Have you had vaginal sex (penis in the vagina), anal sex (penis in the butt), or oral sex (mouth on the penis or vagina) in the past 12 months?
1 Yes
2 No
9 Prefer not to answer [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.
If eligible – Invitation:
Thank you for answering all of the questions. You are eligible to take part in this study. As I mentioned earlier, we are talking to people about HIV and we would like to include your opinions. We would like to invite you to take part in an informal interview/focus group session that will last about 1 hour/2 hours. You will not be asked to buy anything. You will be contacted at a later date to remind you of the interview. Any information that you provide to us will be kept private. We're simply interested in your opinions.
For participating in the interview/focus group, you will receive $50 (interview)/$75 (focus group) as a token of our appreciation.
Would you like to participate in this interview/focus group?
1 Yes [CONTINUE]
2 No [THANK AND END]
10. In what ZIP code do you currently live? _________
11. Before being contacted for this study, had you ever heard of CDC or the Centers for Disease Control and Prevention?
1 Yes
2No
9 Prefer not to answer
[IF “YES” TO INVITATION, READ THE FOLLOWING STATEMENTS…]
“We will be audiotaping the interview/focus group and some project staff from CDC may be observing/listening to the interview/focus group. We may also use a live video stream so project staff from CDC can observe from a computer in another location. In order to participate in the interview/focus group, you must agree to being audiotaped and allowing staff from the CDC to observe. As I said, if you choose to attend, whatever you say will be kept private. We will never link your name with any comment you make in the interview in any report that we write.”
“If you need to wear glasses either for reading or watching TV, please bring them with you to the interview/focus group.”
“Also, we need to let you know that there will not be any childcare provided at the facility, so please make the appropriate childcare arrangements if you have children.”
In order for us to send you a reminder letter/email with directions to the interview/focus group and to call to remind you of your appointment time, I need to ask for your contact information. We will destroy this information after the interview is over.
Participant Information
Interviewer: ________
Date: ________
Letter sent: ________
Reconfirmation: ________ Call |
NAME: _______________________________________________________ ADDRESS: _______________________________________________________ CITY: _______________________________________________________ ZIP CODE: _______________________________________________________ PHONE: Day___________________ Evening ___________________ EMAIL _______________________________________________________ What is the best time to reach you? What is the best telephone number to reach you at that time? If you do not answer, may we leave a private message at that number?
BEST TIME TO BE REACHED: ________________________________________ BEST PHONE NUMBER: ________________________________________
Is there another time and number we can try if we miss you? ALTERNATE PHONE NUMBER: Your participation in this study is very important. If for some reason you will not be able to attend, please let us know right away. You can call us anytime at [insert phone number], and if we are not here, please leave a message. You can also call if you have any questions. Thank you. |
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Peyton Williams |
| File Modified | 0000-00-00 |
| File Created | 2022-06-27 |