MOSAIC Study Sign-up Form_10SEP24

OMB Control Number 0703-MSIC

OMB Expiration Date: XX/XX/XXXX

MOSAIC Sign-up Form

Thank you for your interest in the study! Our research team is looking for volunteer participants in the U.S. Navy who are male survivors of military sexual assault or harassment.

Please continue to the next page to read the informed consent form, then complete the following questions to confirm your eligibility to participate in the study. If you are eligible, a researcher from the Naval Health Research Center will contact you to schedule an interview.

AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information, 0703-MISC, is estimated to average 10 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. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

[Informed Consent will appear here]

Eligibility Check:

Q1 Please select all that apply to you:

• I am an active duty service member in the U.S. Navy.

• I am a Navy veteran who left military service within 2 years of today's date.

• I am 18 or older.

• I identify as a man.

Q2 [This will appear if eligibility criteria are not met]
Thank you for your time and interest in this study. Unfortunately, you do not quality to participate. You may exit the browser at this time.

________________________________________________________________

Q3 When you were in the military…

	Yes	No
did you ever receive uninvited or unwanted sexual attention such as touching, cornering, pressure for sexual favors, or inappropriate verbal remarks, etc.?
did someone ever use force or threat of force to have sexual contact with you against your will?

Q4 [This will appear if eligibility criteria are not met]
Thank you for your time and interest in this study. Unfortunately, you do not quality to participate. You may exit the browser at this time.

Q5 Are you currently involved in any legal proceedings involving military sexual trauma?

• Yes

• No

Q6 [This will appear if eligibility criteria are not met]
Thank you for your time and interest in this study. Unfortunately, you do not quality to participate. You may exit the browser at this time.

Contact Info:

Thank you for your interest in this study! In order to contact you and arrange a time to conduct the interview, please provide a "nickname" and a phone number or email where study staff can reach you. 

Your phone number and/or email will only be used for the purpose of this interview. The information you provide is completely confidential and it will not be given to any third parties.

Please do not include any personally identifiable information (PII) in this section, such as your last name or physical location.


Q7 Nickname (we will use this name when we contact you, so please use a name that you will recognize): 

________________________________________________________________

Q8 Phone number:

________________________________________________________________

OR

Q9 Email:

_______________________________________________________________________

Q10 For scheduling purposes, can research staff text this phone number?

• Yes

• No

Q11 Are you within the continental United States?

• Yes

• No

Q12 Please enter your time zone:

________________________________________________________________

Q13 Typically, when are good times to reach you?

	Time window 1 (e.g., 0900-1200)	Time window 2 (e.g., 1500-1900)
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Q14 Would you prefer a female or male interviewer?

• Female

• Male

• No preference

Q15 Thank you for your time! We will contact you to schedule your interview within the next few days. 

To download a copy of the informed consent form, please click here. 

Some of the questions asked as part of this study are personal and may remind you of difficult or upsetting experiences. You can click here to download a list of resources you may access if you become distressed or upset as a result of participating. If you would like us to do so, we may send you a copy of this resource document at the end of the interview via email.

If you have any questions, please email the study coordinator at [email protected]

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