Quantitative Base Eligibility Screener (English)

Form Approved

OMB No 0920-XXXX

OMB Exp. Date: XX/XX/XXXX

National HIV Behavioral Surveillance System - Brief Biobehavioral HIV Assessments (NHBS-BHBA)

Attachment #3a (English)

Quantitative Base Eligibility Screener (English)

Public reporting burden of this collection of information is estimated to average 1 minute 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 30329; Attn: OMB-PRA (0920-XXXX)

INTERVIEWER ENTERED INFORMATION

	INTERVIEWER: Enter today’s date
	Variable: DATE
	INTERVIEWER: Enter the start time
	Variable: STARTIME
	INTERVIEWER: Enter the interviewer ID
	Variable: ICODE
	_________
	Range…1-99
	INTERVIEWER: Enter the Survey ID
	Variable: SURID
	_________ Must be 4 digits
	Range…0001-9999
	INTERVIEWER: Select the funded state
	Variable: STATE
	Response: funded state
	MA…1
	FL…2
	INTERVIEWER: Select the NHBS-BHBA project area
	Variable: AREA
	Response: project area
	X…1
	Y…2
	Z…3
	INTERVIEWER: Select the priority population for the current interview
	Variable: PPOP
	Response: Priority population
	MSM…1
	PWID…2
	HET…3
	Other…4
	INTERVIEWER: Select the recruitment method
	Variable: METHODS
	Response: recruitment method
	Peer-to-peer…1
	Respondent-driven sampling…2
	Venue-based sampling...3
	Virtual recruitment…4
	Location-based method…5
	Referrals from community partner(s)…6
	Other…7
	If METHODS=Respondent-driven sampling
	INTERVIEWER: Is the respondent a seed?
	Variable: SEED
	Response: Seed status
	No…0
	Yes…1
	If SEED=Yes
	INTERVIEWER: Enter the seed referral number.
	Variable: REFERRAL
	Response: Referral number
	_________
	Range…0001-0888
	Note: Must be 4 digits
	If SEED=No
	INTERVIEWER: Enter the coupon number.
	Variable: COUPON
	Response: Coupon number
	_________
	Range…1000-8888
	Note: Must be 4 digits
	If SEED=No
Intro: I'm going to start by asking you about the person who gave you this coupon and about other people you know in [BHBA location]. Please remember that your answers will be kept private. [Variable: Intro_RDS]
	Question: Which of the following describes how you know the person who gave you this coupon? You can choose more than one answer. [READ choices. CHECK ALL that apply.] [NOTE: Respondent cannot choose stranger along with some other relationship type.]
	Variable: NS_REL
	Response: Relationship to recruiter for RDS
	A relative or family member…1
	A person you have sex with…2
	A person you use drugs with or buy drugs from…3
	A friend…4
	An acquaintance, that is, a person you know but do not consider a friend…5
	A stranger, you don’t know the person or just met them…6
	Refuse to answer…(.R)
	If METHODS=Respondent-driven sampling and PPOP=PWID
Intro: Now, I'm going to ask you about people you know. Specifically, I'm going to ask you how many people you know in [BHBA location] who inject and whom you have seen in the past 30 days. I will not ask you questions about any specific person. [Variable: Intro_RDS_P]
	Question: Please tell me how many men in [BHBA location] you know who inject and whom you have seen in the past 30 days. [If R is not a seed, fill with "Please include the person who gave you the coupon if they are male."]
	Variable: NS_MALE_P
	Response: # male PWID known, net size
	_ _ _ _
	Range 1-7500
	Field note: Range: 1-7500
	Question: How many women in [BHBA location] do you know who inject and whom you have seen in the past 30 days? [If R is not a seed, fill with "Please include the person who gave you the coupon if they are female."]
	Variable: NS_FEMALE_P
	Response: # female PWID known, net size
	_ _ _ _
	Range 1-7500
	Field note: Range: 1-7500
	If METHODS=Respondent-driven sampling and PPOP=HET
Intro: Now, I'm going to ask you about people you know. Specifically, I'm going to ask you how many people you know in [BHBA location] whom you have seen in the past 30 days. I will not ask you questions about any specific person. [Variable: Intro_RDS_H]
	Question: Please tell me how many male friends, relatives or people you associate with have you seen in the past 30 days, who are at least 18 years old, and live in [BHBA location]. [If R is not a seed, fill with "Please include the person who gave you the coupon if they are male."]
	Variable: NS_MALE_H
	Response: # males known, net size
	_ _ _ _
	Range 1-7500
	Field note: Range: 1-7500
	Question: How many female friends, relatives or people you associate with have you seen in the past 30 days, who are at least 18 years old, and live in [BHBA location] do you know who inject and whom you have seen in the past 30 days? [If R is not a seed, fill with "Please include the person who gave you the coupon if they are female."]
	Variable: NS_FEMALE_H
	Response: # females known, net size
	_ _ _ _
	Range 1-7500
	Field note: Range: 1-7500
	If METHODS=Respondent-driven sampling and PPOP=MSM
Intro: Now, I'm going to ask you about men you know and interact with by phone, email, online, or in person. I will not ask you any questions about any specific man. [Variable: Intro_RDS_M]
	Question: First, think about all the men you know who are gay, bisexual, or have sex with other men, who are at least 18 years old, and live in [BHBA location]. Of these men, how many did you interact with in the past 30 days?
	Variable: NS_MSM
	Response: # MSM known, net size
	_ _ _ _
	Range 1-7500
	Field note: Range: 1-7500
	If METHODS= Venue-based sampling
	INTERVIEWER: Venue Code
	Variable: VENUECODE
	_ _ _
	Range 1-999
	Field note: Range: 1-999; Don’t know = 999
	INTERVIEWER: Event Number
	Variable: EVENT
	_ _ _
	Range 1-999
	Field note: Range: 1-999; Don’t know = 999
	If METHODS= Virtual recruitment
	INTERVIEWER: Select the specific virtual recruitment method
	Variable: METHODS_VV
	Response: virtual recruitment method
	Active profile…1
	Advertisement…2
	Direct social networking message…3
	Group message…4
	Passive profile…5
	Post…6
	Other…7
	INTERVIEWER: Venue Code
	Variable: VENUECODE_VV
	_ _ _
	Range 1-999
	Field note: Range: 1-999; Don’t know = 999
	INTERVIEWER: Event Number
	Variable: EVENT_VV
	_ _ _
	Range 1-999
	Field note: Range: 1-999; Don’t know = 999

BASE ELIGIBILITY

Intro: 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. 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. [Variable: Intro_a]
	Question: How old are you?
	Variable: AGE
	Response: Age in years
	Note: If Don’t Know or Refuse to Answer, leave it blank.
	Question: During [fill with current questionnaire year], did you complete any part of this health survey that [insert Project Name] is conducting? It could have been here or at another location.
	Variable: E_PART
	Response: Eligibility, previous participant
	No…0
	Yes…1
	Don’t Know…(.D)
	Refuse to Answer…(.R)
	If E_PART=1
	[INTERVIEWER: probe to determine if participation was for the same quantitative BHBA interview. If no, go back to E_PART and change response to “No”.]
	Variable: Probe
	Question: What county do you currently live in?
	Variable: E_COUNTY
	Response: County of residence
	[Display list of local counties]
	Don't Know…(.D)
	Refuse to Answer…(.R)
DISPLAY: "The next questions are about languages you speak." [Variable: langmod]
	Question: How well do you speak English?
	Variable: ENGPFCY
	Response: English Proficiency
	Very well…1
	Well…2
	Not well…3
	Not at all…4
	Don’t Know…(.D)
	Refuse to Answer…(.R)
	Question: How well do you speak Spanish?
	Variable: SPNPFCY
	Response: Spanish Proficiency
	Very well…1
	Well…2
	Not well…3
	Not at all…4
	Don’t Know…(.D)
	Refuse to Answer…(.R)
Interviewer Assessment
	INTERVIEWER: Is this person alert and capable of completing the survey in English or Spanish?
	Variable: E_CAP
	Response: Able to complete survey
	No…0
	Yes…1
	If E_CAP = No
	INTERVIEWER: Specify reason person not able to complete the interview: [CHECK ALL THAT APPLY.]
	Variable: E_CAPA
	Response: Reason not able to complete
	Not able to understand or consent
	Cannot speak and understand English or Spanish
	INTERVIEWER: Did your field supervisor tell you that this person cannot complete the survey for some other reason?
	Variable: E_FS
	Response: Field supervisor reason
	No…0
	Yes…1
	If E_FS = Yes
	INTERVIEWER: Specify other reason person not able to complete the interview: [CHECK ALL THAT APPLY.]
	Variable: E_FSMI
	Response: Other reason
	Known previous participant
	Reported age not plausible (e.g., <18 years old)