Quantitative Base Eligibility Screener (English)

National HIV Behavioral Surveillance: Brief HIV Bio-behavioral Assessment (NHBS-BHBA)

Att 3a_Quantitative Base Eligibility Screener_Eng_20220805_clean

Quantitative Base Eligibility Screener

OMB: 0920-1398

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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)





File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorMorris, Elana (CDC/DDID/NCHHSTP/DHP)
File Modified0000-00-00
File Created2022-10-03

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