Qualitative 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 #3e (English)

Qualitative 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)

Eligibility Screener Questions

[Remember to modify to include questions based on your project area’s needs, population of interest and mode, e.g., CKI, PKI, focus group].

1. What neighborhood do you spend most of your time in?

If they live in [insert local project area/county], continue the interview.

If they do not live in [insert local project area/county], stop and thank the person for their time.

2. How old are you? ___________

If ≥18 years of age, continue interview.

If <18 years of age, stop and thank person for their time.

3. [Add in questions about population-specific eligibility criteria.]