Form 0920-22FZ Att 4g_Provider Screener

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

mChoice: Improving PrEP Uptake and Adherence among Minority MSM through Provider Training and Adherence Assistance in Two High Priority Settings

Attachment 4g

Provider Screener

Public reporting burden of this collection of information 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. 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)

mChoice Aim 3 Provider Screener

Record ID __________________________________

Screening Date __________________________________

(NOT PARTICIPANT FACING)

This screening form can be used by study team members to screen volunteers over the phone. Alternatively,

volunteers can be sent the screener link and complete the first part on their own. A study team member will then

contact initially eligible participants to continue with the screening questions that must be completed over the

phone. If the form status has a checkmark, please click the "Edit response" button at the top of the page to enter

data. All questions marked with "not participant facing" are hidden from volunteers on the screening form, but are

visible to study team members. *not participant facing*

Thanks for your interest in the mChoice study: Improving PrEP Uptake and Adherence among Minority MSM through

Tailored Provider Training and Adherence Assistance in Two High Priority Settings (mChoice)! The study intends to enroll 20 clinical providers and clinical staff who work at the following locations in New York City, NY and Birmingham, AL: Columbia University Nurse Practitioner Primary Care Group, Callen-Lorde Community Health Center, University of Alabama at Birmingham (UAB) 1917 Clinic, and Birmingham AIDS Outreach (BAO). First, let's give you a bit of information about the study. Then, if you are interested, you will have the opportunity to screen to see if you are eligible to participate.

We are providing training to healthcare providers to improve knowledge of PrEP clinical recommendations and enhance provider communication. The provider training will be presented in the form of a video composed of 3modules that can be paused and continued at any time. This video will also include pre- and post-assessments to measure the training’s usefulness and efficacy for advancing PrEP knowledge. Each assessment is expected to take 20 to 30 minutes to complete. The provider training modules can be completed on the participant’s own schedule over the course of six months. Participants who complete the pre- and post-assessments of the provider training modules will receive a $50 incentive.

At the end of the six-month period, participants will be asked to participate in an in-depth interview to assess the impact of provider training. The interview is expected to last between 45 minutes and an hour. Participants who complete the interview will receive a $100 incentive.

Participating providers may also be asked to fill out a clinic assessment tool at the clinic where they work every six months for a period of 36 months total.

This study is run by the Columbia University School of Nursing and is paid for by the Centers for Disease Control & Prevention (CDC). All of the data we collect will be coded and linked to identifiers to maintain confidentiality. The study is completely voluntary. You can decide that you don’t want to participate at any time. If you have any questions about your rights as a research participant, or if you have any questions, concerns or complaints about this study, you may contact: 

Human Research Protection Office, 

Institutional Review Board, Columbia University Medical Center, 

Address: 154 Haven Avenue, 1^st Floor; New York, NY 10032, 

Telephone: (212) 305-5883, 

Email: [email protected] 

If this sound like something you'd be interested in, we can screen you to determine if you are a good fit for this

study. You can complete the first part of the screening below, and, if initially eligible, a team member will contact you

to complete the screening process.

Are you interested in seeing if you're eligible for this study?

	Yes, online right now
	No (If you answer “No” you will not be asked the screening questions)

[IF “No” selected above then display & end screening]

Would you mind sharing why this project doesn't interest you? _______________________________

If you change your mind, you can reach us at: NYC: 212-305-8198 Birmingham: 205-996-7984. Don't forget to click

"Submit" below!

[IF “Yes” selected above then display following questions 1-4]

How did you hear about the mChoice study?

	Printed Material – Flyer
	Hospital/Primary Care clinic
	Email Message
	Previous study
	Referral from someone I know (friend, coworker, etc.)
	Other

Please specify (do not use names or other identifying information): __________________________________________

Contact Information

Full Name: __________________________________

Phone number: __________________________________

Email address: __________________________________

1. Are you at least 18 years old?

	Yes
	No

2. At which participating site do you work?

	Columbia University Nurse Practitioner Primary Care Group
	Callen-Lorde Community Health Center
	University of Alabama at Birmingham (UAB) 1917 Clinic
	Birmingham AIDS Outreach (BAO)
	None of these locations

3. What is your job role?

	Clinical provider
	Clinical staff
	Implementation staff
	None of the above

4. Can you speak, read, and write in English?

	Yes
	No

Submission

Thank you for taking the time to answer our screening questions! A team member may reach out to you to complete

the screening process with the contact information you provided.

Please click the "Submit" button below.

Preliminary eligibility calculation __________________________________

(NOT PARTICIPANT FACING )

Participant is likely eligible for the study! Please review the screener to make sure they are eligible.

If they are, try to schedule them.

Participant might be ineligible for the study! Please review the screener to make sure they are ineligible. If so, ask if we can keep their contact info to be contacted for future studies.

Staff: review screener & indicate volunteer eligibility: *NOT PARTIICPANT FACING*

	Eligible
	Ineligible
	Incomplete
	Possibly rescreen
	Not screened

Staff: reason(s) ineligible *NOT PARTICIPANT FACING*

	Age
	Location not included in study
	Work role not eligible for participation
	Language
	Cognitive ability

Screener notes: __________________________________________

(NOT PARTICIPANT FACING)