Registration Contact Information Form

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Understanding HIV/STD Risk and Enhancing PrEP Implementation Messaging in a Diverse Community-Based Sample of Gay, Bisexual, and Other Men Who Have Sex with Men in a Transformational Era (MIC-DROP)

Attachment 4b

Registration Contact Information Form 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 30333; Attn: OMB-PRA (0920-New)

IRB Approved at the Protocol Level

Jun 21, 2023

20225896

#35745353.2

MIC-DROP Registration Contact Form - English

Based on your answers, you may qualify to enroll in our study. Please provide the following information (first and last name, phone number, email address and contact preference) so we may contact you to schedule your participation in the study. The information you provide here will be kept separate from other information you provide to us in the course of this study, and access to any contact information you provide will be limited to key study staff.

Please take a moment to review your answers before submitting them. Please make sure that your contact information is accurate, as inaccurate contact information may prevent us from being able to contact you.

1. What is the current, 10-digit phone number for the mobile phone you plan to use during this study? This should be a device that you are able to receive text messages on with important information such as reminders to complete more health surveys.

Phone number: (__ __ __) -- __ __ __ -- __ __ __ __*

[PHNNUMB]

[using form validation, if provided phone number does not have 10 digits, reject entry and prompt user correction with: “You must provide a valid, 10-digit phone number to participate in our study.”]

2. What is your current email address? __________________________________

[EMAIL]

Please provide us with a shipping address so we can send you HIV/STI home test kits during the study. The package will arrive in a plain shipping box. You may choose to receive packages at home, at a family member’s address, or a friend’s address. However, we cannot ship to a P.O. Box. If you cannot provide a shipping address you cannot participate in our study.

3. Enter shipping address:

Address 1: ____________________ [ADDRESS1]

Address 2: ____________________ [ADDRESS2]

City: ____________________ [CITY]

State: ____________________ [STATE]

ZIP Code: ____________________ [ZIP]

4. What type of address is this?

(1) My home or residential address (house, apartment, condo)

(2) Someone else’s home or residential address (house, apartment, condo)

(3) My office or work location

(4) Someone else’s office or work location

(5) Post office or other shared mailbox (PO Box)

(6) Community based organization or health center

(7) Other, please specify______ [ADDRESS_TYPE_OTHER]

[ADDRESS_TYPE]

Source: Created

5. If study staff contact you regarding participation in the study, how would you most prefer to be contacted? Please select one.

1. Phone Call

2. Text Message

3. Email

4. No preference

[CONTACT]

If study staff contact you regarding participation in the study, they will first attempt to contact you by the contact method you prefer. If unable to make contact by the preferred method, study staff will attempt to make contact by other means.

During this study, we will not connect your name with any survey responses you provide. We prefer having a first and last name, as this name will also be displayed on the package mailed to you as part of this study. You will need to know by the name on the package that it is for you.

6. What is your Full Name? Please include a first and last name*

_________ ___________

[FIRSTNAME]

[LASTNAME]

[using form validation, if provided name has 0 characters, reject entry and prompt user correction with: “You must provide a full name to participate in our study.”]

7. Please provide us with your name, or if you prefer, a nickname, alias or name of your choice that we can use throughout the study to communicate with you. _______________________

[NICKNAME]

End: If the participant provides the required information (phone number & mailing address):

Congratulations! You are registered to participate in this health study.

The next step is to complete a virtual enrollment study visit along with a baseline health survey. You will be contacted by study staff to schedule your virtual enrollment study visit. Please note that this can take up to two weeks. At any time, you may contact the Study Coordinator at [study email] or [study phone number] with questions.

Thank you!