Qualitative Eligibility Screener (Spanish)

Form Approved

OMB No 0920-XXXX

OMB Exp. Date: XX/XX/XXXX

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

Attachment #4e (Spanish)

Qualitative Eligibility Screener (Spanish)

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)

Preguntas para determinar la elegibilidad

[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. ¿En qué vecindarios pasa la mayor parte de su tiempo?

Si vive en [insert local project area/county], continúe la entrevista.

Si no vive en [insert local project area/county], deténgase y agradezca a la persona por su tiempo.

2. ¿Qué edad tiene? ___________

Si tiene ≥18 años, continúe la entrevista.

Si tiene <18 años, deténgase y agradezca a la persona por su tiempo.

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