0920-1423 Aim 2b Provider Pre-Focus Group Survey_23DEC2024

Form Approved

OMB No. 0920-1423

Expiration Date: 12/31/2026

Expanding PrEP in Communities of Color (EPICC+)

Attachment 4p

Aim 2b Provider Pre-Focus Group Survey

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)

Provider Pre-Focus Group Survey 26 February 2023

Thank you for your participation in this important project. This survey will take approximately 5 minutes to complete.

In this survey, we will ask some questions about your demographics and your role in your clinic. This survey includes questions around sensitive topics. Before beginning, please consider your surroundings and the privacy of your device and internet connection.

All the information you enter in this survey is encrypted and kept completely confidential. Your answers are private--the information you provide us will be kept secure and known only to study staff. You may choose "Decline to answer" on any questions that make you feel uncomfortable.

A Note about Language

We want to acknowledge that some of the language used in our study questions may include some outdated language or lack the diversity of experiences that we now understand exist. Although we do our best to use measures that reflect emerging language, at times the items available in research are not where they need to be and are drawn from items developed ten (or more) years ago. Wherever possible, we have updated the language or are working with developers to get new versions. Please remember that you can always decline to answer items that do not reflect you.

If you have any questions or comments, please contact study staff at [email protected] or (448) 488- 9069.

1. What is your age (in years)?

   • Decline to answer

2. What is your race and/or ethnicity? Select all that apply and enter additional details in the spaces below.

• American Indian or Alaska Native –

Enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc._________________________

• Asian – Provide details below.

  • Chinese

  • Asian Indian

  • Filipino

  • Vietnamese

  • Korean

  • Japanese

Enter, for example, Pakistani, Hmong, Afghan, etc. ____________________

• Black or African American - Provide details below.

  • African American

  • Jamaican

  • Haitian

  • Nigerian

  • Ethiopian

  • Somali

Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc._____________

• Hispanic or Latino – Provide details below.

  • Mexican

  • Puerto Rican

  • Salvadoran

  • Cuban

  • Dominican

  • Guatemalan

Enter, for example, Colombian, Honduran, Spaniard, etc. ___________________

• Middle Eastern or North African – Provide details below.

  • Lebanese

  • Iranian

  • Egyptian

  • Syrian

  • Iraqi

  • Israeli

Enter, for example, Moroccan, Yemeni, Kurdish, etc._______________

• Native Hawaiian or Pacific Islander – Provide details below.

  • Native Hawaiian

  • Samoan

  • Chamorro

  • Tongan

  • Fijian

  • Marshallese

Enter, for example, Chuukese, Palauan, Tahitian, etc.______________________

• White – Provide details below.

  • English

  • German

  • Irish

  • Italian

  • Polish

  • Scottish

Enter, for example, French, Swedish, Norwegian, etc. _________________

3. Which of the following BEST represents how you think about yourself?

   1. Lesbian or gay

   2. Straight, that is not lesbian or gay

   3. Bisexual

   4. Something else:_____________

   5. Decline to answer

[If American Indian or Alaskan Native is not checked]

3. How do you currently describe yourself? (Check all that apply)

• Woman, including transgender woman

• Man, including transgender man

• Nonbinary, including gender nonconforming, and genderqueer

• A different gender identity: ____________

• Don’t know

• Decline to answer

[If American Indian or Alaskan Native is checked]

3. How do you currently describe yourself? (Check all that apply)

• Woman, including transgender woman

• Man, including transgender man

• Nonbinary, including gender nonconforming, and genderqueer

• Two-Spirit

• A different gender identity: ____________

• Don’t know

• Decline to answer

3. What sex were you assigned at birth, on your original birth certificate?

• Male

• Female

• Intersex

• Decline to answer

26 February 2023

3. What is your current role in the clinic?

   1. Clinician (MD, PA, NP, etc.)

   2. Nurse

   3. Medical assistant

   4. Social worker or case manager

   5. Adherence counselor

   6. Peer advocate

   7. Other, please specify:

   8. Decline to answer

4. Can you prescribe PrEP?

   1. Yes

   2. No

   3. Decline to answer

5. How many years have you been at your current clinic?

   1. Decline to answer

3. Do you work directly with clients?

   1. Yes

   2. No

   3. Decline to answer