Quantitative Population 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 #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]