Quantitative Population Eligibility Screener (English)

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

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Quantitative Population Eligibility Screener

OMB: 0920-1398

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

Attachment #3b (English)

Quantitative Population Eligibility Screener (English)

















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 30329; Attn: OMB-PRA (0920-XXXX)





POPULATION ELIGIBILITY



Question Set Intro: The following questions are about your sex assigned at birth, which is the sex listed on your original birth certificate, AND about your gender identity, which is the way you describe your gender. [Variable: qsintro_mh]


Question: What sex were you assigned at birth?


Variable: SXBRTH


Response: Sex at birth


Male…1


Female…2


Intersex/ambiguous…3


Don’t Know…(.D)


Refuse to Answer…(.R)




Question: Which of the following best describes your gender?


Variable: GEND


Response: Gender


Man…1


Woman…2


Nonbinary…3


Don’t Know…(.D)


Refuse to Answer…(.R)



Question Set Intro: The next set of questions are about your race and ethnicity. [Variable: intro_demo]


Question: Do you consider yourself to be of Hispanic or Latino/a origin?


Variable: HISPANIC


Response: Latino ethnicity


Yes…1


No…0


Don’t Know…(.D)


Refuse to Answer…(.R)




If R is Latino go to next question.




Question: Which of the following describes your Hispanic, Latino/a, or Spanish origin? You may choose more than one option. l


Variable: HSPTYP


Response: Hispanic Ancestry


Mexican…1


Puerto Rican…2


Cuban…3


Dominican…4


Another Hispanic, Latino/a, or Spanish origin…5


Don’t Know…(.D)


Refuse to Answer…(.R)




If R report 'another' Hispanic origin, go to next question.




Question: What is your Hispanic, Latino/a, or Spanish origin?


Variable: SPECHSP


Response: Other specified Latino origin


Text response: ____________________________




Question: 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.]


Variable: Race


Response: Racial group


American Indian or Alaska Native…1


Asian…2


Black or African American…3


Native Hawaiian or Other Pacific Islander…4


White…5


Don’t Know…(.D)


Refuse to Answer…(.R)


Not applicable…(.N)




Question: Next I would like to ask you some questions about your background. What country were you born in? [DO NOT read choices.]


Variable: COUNTRY


Response: Country of birth


United States…1


Mexico…1


Puerto Rico…3


Cuba…4


Other…5


Don’t Know…(.D)


Refuse to Answer…(.R)




If R report 'other' country, go to next question.




INTERVIEWER: Specify other country of birth


Variable: SPECBORN


Response: Specify country of birth


Text response: ____________________________



"Intro: Next, I'd like to ask you some questions about where you live. Please remember your answers will be kept private." [Variable: intro_home]


Question: In the past 12 months, that is, since [fill with interview month] of last year, have you been homeless at any time? By homeless, I mean you were living on the street, in a shelter, in a Single Room Occupancy hotel (SRO), or in a car.


Variable: PYHOMLS


Response: Homeless during past 12 months


No…0


Yes…1


Don’t Know…(.D)


Refuse to Answer…(.R)




If EVRHOMLS=yes


Question: Are you currently homeless?


Variable: CURHMLSS


Response: Currently homeless


No…0


Yes…1


Don’t Know…(.D)


Refuse to Answer…(.R)



Intro: The next question is about your household income. By “household income”, I mean the total amount of money earned and shared by all people living in your household. [intro_inc]


Question: What was your household income in [Fill with year before interview] from all sources before taxes? Please take a look at this card and tell me the letter that matches your monthly or yearly income. [Give respondent Flashcard A]


Variable: HHINC


Response: Household income


A - 0 to $416 (M) 0 to $4,999 (Y)…1        


B - $417 to $833 (M) $5,000 to $9,999 (Y)…2        


C - $834 to $1041 (M) $10,000 to $12,499 (Y)…3        


D - $1042 to $1249 (M) $12,500 to $14,999 (Y)…4        


E - $1250 to $1666 (M) $15,000 to $19,999 (Y)…5        


F - $1667 to $2083 (M) $20,000 to $24,999 (Y)…6        


G - $2084 to $2499 (M) $25,000 to $29,999 (Y)…7        


H - $2500 to $2916 (M) $30,000 to $34,999 (Y)…8        


I - $2917 to $3333 (M) $35,000 to $39,999 (Y)…9         


J - $3334 to $4166 (M) $40,000 to $49,999 (Y)…10         


K - $4167 to $4999 (M) $50,000 to $59,999 (Y)…11         


L - $5000 to $6249 (M) $60,000 to $74,999 (Y)…12        


M - $6250 to $8332 (M) $75,000 to $99,999 (Y)…13         


N - $8333 or more (M) $100,000 or more (Y)…14                         


Don’t Know…(.D)


Refuse to Answer…(.R)




Question: Including yourself, how many people depended on this income?


Variable: DEPEND


Response: Number of Dependents


Numerical Response:____ (must be at least 1)



"Intro: Now I will ask you about experiences you may have had with the criminal justice system." [Variable: intro_cjs]



Question: Have you ever been held in a detention center, jail, or prison for more than 24 hours?



Variable: EVHELD



Response: Ever held or arrested



No…0



Yes…1



Don’t Know…(.D)



Refuse to Answer…(.R)






If EVHELD=yes



Question: During the past 12 months, that is, since [fill with interview month] of last year, have you been held in a detention center, jail, or prison for more than 24 hours?



Variable: HELD12MO



Response: Held or arrested past 12 months



No…0



Yes…1



Don’t Know…(.D)



Refuse to Answer…(.R)




Intro: The next questions are about having sex. For these questions, "having sex" means oral, vaginal, or anal sex. I need to ask you these questions even if some don't apply to you. Please remember your answers will be kept private. [intro_sx]


Question: In the past 12 months, that is, since [fill with interview month] of last year, have you had sex?


Variable: SEX12


Response: Had sex, past 12 mos.


No…0


Yes…1


Don’t Know…(.D)


Refuse to Answer…(.R)




If SEX12=yes


Question: In the past 12 months, with whom have you had oral, vaginal or anal sex? You may choose more than one option.

[READ choices. Mark all that apply.]


Variable: SXGENDER


Response: Gender of sex partners


Men…1


Women…2


People with other gender identities…3


Don’t Know…(.D)


Refuse to Answer…(.R)



Intro: Now I am going to ask you about experiences you may have had with injecting drugs. This includes injecting drugs like heroin, methamphetamine, Oxycontin, or any other drug that was not prescribed for you. It also includes injecting drugs that were prescribed for you that you used in a way other than instructed by your healthcare provider. [intro_pw]


Question: Have you ever in your life shot up or injected any drugs other than those prescribed for you? By shooting up, I mean any time you might have used drugs with a needle.


Variable: EVRINJ


Response: Ever injected


No…0


Yes…1


Don’t Know…(.D)


Refuse to Answer…(.R)




If EVRINJ=1


Question: When was the last time you injected any drug? That is, how many days or months or years ago did you last inject?


Variable: LINJN


Response: When last injected, number


Range: 0-365 (if today, enter "0")


Note: If Don’t Know or Refuse to Answer, leave it blank.




If EVRINJ=1 and LINJN= 0-365


Question: Was this days or months or years?


Variable: LINJU


Response: When last injected, unit


Days…0


Months…1


Years…2


Don’t Know…(.D)


Refuse to Answer…(.R)




If (LINJU=0 and LINJN<=365), 1, if ((LINJU=1 and LINJN<=12), 1, if ((LINJU=2 and LINJN <=1)


Question: In the past 12 months, which drugs have you injected? Please say “yes” or “no” to each drug I mention.


Variable: INJDRUG


Response: Drugs injected

injdruga

Speedball, which is heroin and cocaine together…1

injdrugb

Heroin and methamphetamine together, such as goofball…2

injdrugc

Fentanyl, by itself or in combination with other drugs…3

injdrugd

Heroin, by itself…4

injdruge

Methamphetamine, by itself, also known as meth, crystal meth, speed or crank…5

injdrugf

Powder cocaine, by itself…6

injdrugg

Crack cocaine, by itself…7

injdrugh

Painkillers, such as Oxycontin, Dilaudid, or Percocet

injdrugi

Benzodiazepines or other downers, such as Valium, Xanax, or Klonopin

injdrugj

Methadone…10

injdrugk

Buprenorphine, also known as Suboxone or Subutex…11

injdrugl

Something else…12


Don’t Know…(.D)


Refuse to Answer…(.R)



ELIGIBILITY


INTERVIEWER: Has the respondent completed the population eligibility form?


Variable: ppopverify


Response: population eligibility form completion


No... 0


Yes... 1




MSM Eligible: if SXBRTH=Male and GEND=Man and SXGENDER=Men and PPOP=MSM


HET Eligible: if (SXBRTH=Male and GEND=Man and SXGENDER=Women) or (SXBRTH=Female and GEND=Woman and SXGENDER=Men) and AGE <= 60 and PPOP=HET


PWID Eligible if INJ12 = if ((LINJN=0), 1, if (LINJU=0 and LINJN<=365), 1, if ((LINJU=1 and LINJN<=12), 1, if ((LINJU=2 and LINJN <=1), 1, 0))) and PPOP=PWID




If base eligibility = yes and population eligibility = MSM, HET, PWID


Intro: “Congratulations! The computer has selected you to participate in the health survey. Let me tell you about it. [INTERVIEWER: Proceed with the consent process.]” [variable: intro_selected]


If base eligibility = no OR population eligibility NE MSM, HET, PWID


Intro: "Thank you for answering these questions. Unfortunately, the computer has not selected you to participate in the health survey. Thank you again for your time.” [variable: intro_notselected]






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AuthorMorris, Elana (CDC/DDID/NCHHSTP/DHP)
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File Created2022-10-03

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