Screening

Attachment 6: Screening Instrument

for

Qualitative Evaluation of HIV Counseling, Testing, and Referral Services in Non-Health Care Settings: Eliciting Consumer Views

New OMB Application

Technical Monitor: Dorothy Gunter, MPH
Senior Advisor, Science and Program Integration

Address:
1600 Clifton Rd, NE
MS D21
Atlanta, GA 30333

Telephone: 404-639-6436
Fax: 404-639-1950
E-mail: dorothy.gunter@cdc.hhs.gov

Date: September 12, 2007

SCREENING

OMB Approved

OMB No

Exp. date

INTRODUCTION AND Verbal Consent SCRIPT

Reading level 5.8 (assessed by Flesch-Kincaid)

READ: “Hello, my name is __________ and I’m from ____________ (name of company/organization). We are inviting people to be in a focus group that is part of a research study.

The group will have about 9-12 people. People in the group will get together one time for about 2 hours to talk about a topic. The topic of the focus group is HIV testing experiences and places where people might go to get an HIV test.

RTI International, a nonprofit company in North Carolina, is conducting the groups. The Centers for Disease Control and Prevention--or CDC-- is sponsoring the groups.

We are recruiting people with differing backgrounds and characteristics. Some of the questions I would like to ask you now will help us see if you are eligible to take part in one of the groups. Others will help us describe all of the people we have talked to. Some of these questions may be personal such as your sexual and drug using behavior. We will also ask about your HIV status. It is your choice to answer the questions. Your answers will be kept private. You can choose not to answer a question or stop at any time. The questions will take 20 minutes to complete.

If you are eligible and are interested, we will assign you to a focus group. We will ask you if this assignment is okay with you. Everything you tell us in the focus group will be private. We will never link your name with any of your comments. If you join a focus group, we will give you $50 for your time and effort.

May I ask you the questions now?”

Yes  CONTINUE

No  TERMINATE

SECTION 1

GATEWAY

1.1. How old are you?

INELIGIBLE	Under 15  SKIP to Section 8A	1
	15-17  SKIP to Section 2 Adolescents Record Age 
	18-64  CONTINUE Record Age 
INELIGIBLE	Over 64  SKIP to Section 8A	2
INELIGIBLE	Don’t know  SKIP to Section 8A	3
INELIGIBLE	Decline to answer  SKIP to Section 8A	4

1.2a Have you participated in an HIV-related study in the past six (6) months?

INELIGIBLE	Yes  SKIP to Section 8A	1
	No  CONTINUE	2
INELIGIBLE	Don’t Know  SKIP to Section 8A	3
INELIGIBLE	Decline to answer SKIP to Section 8A	4

1.2b Have you participated in a focus group in the past six (6) months?

INELIGIBLE	Yes  SKIP to Section 8A	1
	No  CONTINUE	2
INELIGIBLE	Don’t Know  SKIP to Section A	3
INELIGIBLE	Decline to answer  SKIP to Section 8A	4

1.3a. Are you Hispanic or Latino?

Yes	1
No	2
Don’t know	3
Decline to answer	4

1.3b. What is the category that best describes your racial background? [READ RESPONSES 1-5 AND MARK ONLY ONE]

American Indian or Alaskan Native	1
Asian	2
Black or African American	3
Native Hawaiian or Other Pacific Islander	4
White	5
Other: [RECORD]:	6
None	7
Don’t know	8
Decline to answer	9

1.4 What is your gender? [Read ALL responses. Do not assume]

	Male  SKIP to 1.5	1
	Female  SKIP to 1.5	2
	Transgender or Transsexual  Continue	3
INELIGIBLE	Decline to answer  SKIP to Section 8A	4

1.4a. Are you a male-to-female or female-to-male transgender or transsexual person?

	Male to Female SKIP to Section 3 MTF Transgender	1
INELIGIBLE	Female to Male  SKIP to Section 8A	2
INELIGIBLE	Decline to answer  SKIP to Section 8A	3

1.5 The next question is about injecting, “shooting,” or “skin popping” drugs. This means injecting drugs with a needle or a syringe yourself or having someone who isn’t a health care provider inject you. Do not include hormones, or drugs that were given or prescribed by a health care professional for things like allergies, diabetes, or HIV medications. Please remember your answer will be kept private. In the past twelve (12) months, have you injected drugs?

	Yes  SKIP to Section 4 IDU	1
	No  Continue	2
	Don’t know  Continue	3
	Decline to answer  Continue	4

1.6 Have you ever been tested for HIV?

	Yes  Continue	1
	No  SKIP to Section 5 Potential Clients	2
INELIGIBLE	Don’t know  SKIP to Section 8A	3
INELIGIBLE	Decline to answer  SKIP to Section 8A	4

1.7a. The next question is about the result of your HIV test. We are recruiting people who are positive and negative for the study. With that in mind, what was the result of your most recent HIV test? (Read options.)

	I tested positive for HIV  Continue	1
	I tested negative for HIV No  SKIP to 1.8	2
	My results were unclear / Don’t Know  SKIP to1.8	3
	I never got my results  SKIP to 1.8	3
INELIGIBLE	Decline to answer  SKIP to Section 8A	4

1.7b [If positive] When did you first test positive? DATE (mm/dd/yy):__________

INELIGIBLE	More than 5 years ago  SKIP to Section 8A	1
	5 or less years ago  SKIP to Section 6 HIV-Positive Past Client	2
INELIGIBLE	Don’t Know  SKIP to Section 8A	3
INELIGIBLE	Decline to answer  SKIP to Section 8A	4

1.8 [If negative or unknown] When was your last HIV test?

	Five or more years ago  SKIP to Section 5 Potential Clients	1
	Within the past 12 months  SKIP to Section 7 HIV-Negative or Unknown Past Client	2
INELIGIBLE	Between 1 and 5 years ago  SKIP to Section 8A
INELIGIBLE	Don’t Know  SKIP to Section 8A	3
INELIGIBLE	Decline to answer  SKIP to Section 8A	4

SECTION 2

ADOLESCENT

2.1. Before we begin, I have three questions I want to ask you to make sure you understood the verbal consent I just read to you. [Do not correct person on answers until the end of the 3 question series.]

2.1a. Do you have to answer all of the questions that I ask you?

INCORRECT	Yes	1
CORRECT	No	2
	Don’t Know	3
	Decline to answer	4

2.1b. Will your name be connected to your answers?

INCORRECT	Yes	1
CORRECT	No	2
	Don’t Know	3
	Decline to answer	4

2.1c. Are we going to ask you about sexual behavior?

CORRECT	Yes	1
INCORRECT	No	2
	Don’t Know	3
	Decline to answer	4

SCORING

• If all answers correct, CONTINUE.

• If one (1) answer incorrect, reread the relevant portion of the verbal consent that pertains to the question and re-ask the question. If correct, CONTINUE. Else, SKIP TO SECTION 8B.

• IF two (2) or more answers are incorrect, don’t know, or decline to answer, SKIP TO SECTION 8B.

2.2a Have you participated in an HIV-related study in the past six (6) months?

INELIGIBLE	Yes  SKIP to Section 8A.	1
	No  CONTINUE	2
INELIGIBLE	Don’t Know - SKIP to Section 8A	3
INELIGIBLE	Decline to answer  SKIP to Section 8A	4

2.2b Have you participated in a focus group in the past six (6) months?

INELIGIBLE	Yes  SKIP to Section 8A	1
	No  CONTINUE	2
INELIGIBLE	Don’t Know  SKIP to Section 8A	3
INELIGIBLE	Decline to answer SKIP to Section 8A	4

2.3a. Are you Hispanic or Latino?

Yes	1
No	2
Don’t know	3
Decline to answer	4

2.3b. What is the category that best describes your racial background? [READ RESPONSES 1-5 AND MARK ONLY ONE]

American Indian or Alaskan Native	1
Asian	2
Black or African American	3
Native Hawaiian or Other Pacific Islander	4
White	5
Other: [RECORD]:	6
None	7
Don’t know	8
Decline to answer	9

2.4a. What is your gender? [Read ALL responses. Do not assume]

	Male [Skip to 2.5]	1
	Female [Skip to 2.5]	2
	Transgender or Transsexual [continue]	3
INELIGIBLE	Decline to answer	4

2.4b. Are you a male-to-female or female-to-male transgender or transsexual person?

Male-to-Female	1
Female-to-Male	2
Decline to answer	3

2.5 Have you ever been tested for HIV?

	Yes  Continue	1
	No  SKIP to 2.12a	2
INELIGIBLE	Don’t know  SKIP to Section 8A	4
INELIGIBLE	Decline to answer  SKIP to Section 8A	5

2.6. The next question is about the result of your HIV test. We are recruiting people who are positive and negative for the study. With that in mind, what was the result of your most recent HIV test? (Read options.)

	I tested positive for HIV  Continue	1
	I tested negative for HIV  SKIP to 2.10	2
	My results were unclear / Don’t Know  SKIP to 2.10	3
	Did not get test results / Don’t Know  SKIP to 2.10	4
INELIGIBLE	Decline to answer  SKIP to Section 8A	5

[IF HIV POSITIVE ADOLESCENT]

2.7 When did you first test positive? DATE (mm/dd/yy):__________

INELIGIBLE	More than 5 years ago  SKIP to Section 8A	1
	Within the past 5 years  Continue	2
INELIGIBLE	Don’t Know  SKIP to Section 8A	3
INELIGIBLE	Decline to answer  SKIP to Section 8A	4

2.8 Where did you first test positive? [Probe if more information is needed: “Tell me a little more about the place where the test was done.”]

Medical Settings		Non-Medical Settings
	Hospital or Clinic		Homeless Shelter
	STD/AIDS Clinic		An Outreach Program (e.g. syringe exchange programs, bars, health fair, bath houses.)
	Doctor’s Office		Mobile HIV Testing Unit (such as a van)
	Drug Treatment Facility		Jail or prison
	Mental Health Treatment Facility		Community-based organization
	Other:_____________________		Other:__________________________
	If yes to above DEFINE as “tested in medical setting.” Aim for a MAXIMUM of 2 in each group.		If yes to above DEFINE as “tested in non-medical setting.”

2.9 Now I am going to ask you to describe your sexual identity. Would you describe yourself as [READ]:

Homosexual or “gay”	1
Bisexual	2
Heterosexual or “straight”	3
Other	4
Don’t know	5
Decline to answer	6

RECRUIT ELIGIBLE HIV POSITIVE ADOLESCENTS

If 2.4a=1 (male) or 2 (female):

[ASK] Based on your answers, you are eligible to be in our group with other [males/females] who are also HIV positive. Is this okay with you?

	Yes  RECRUIT as HIV POSITIVE ADOLESCENT. Segment by gender (Q 2.4). Skip to Section 9	1
INELIGIBLE	No  Skip to Section 8B	2
INELIGIBLE	Don’t know  Skip to Section 8B	3
INELIGIBLE	Decline to answer  Skip to Section 8B	4

If 2.4a=3 (transgender or transsexual):

[ASK] Based on your answers, you are eligible to be in our group with other people your age who are also HIV positive. Is this okay with you?

	Yes  RECRUIT as HIV POSITIVE ADOLESCENT. Skip to Section 9	1
INELIGIBLE	No  Skip to Section 8B	2
INELIGIBLE	Don’t know  Skip to Section 8B	3
INELIGIBLE	Decline to answer  Skip to Section 8B	4

[ASK] We will have two groups, one for males and one for females. Which group would you feel most comfortable in?

	Male  Segment into male HIV positive group.	1
	Female  Segment into female HIV positive group.	2
INELIGIBLE	Neither   Skip to Section 8B	3

[CONTINUE SCREENER IF NEVER TESTED OR HIV NEGATIVE/UNKNOWN]

2.10 When was your last HIV test? DATE (mm/dd/yy):__________

	Five or more years ago  SKIP to 2.12a	1
	Within the past 12 months  Continue	2
INELIGIBLE	Between 1 and 5 years ago  SKIP to Section 8A	3
INELIGIBLE	Don’t Know  SKIP to Section 8A	4
INELIGIBLE	Decline to answer  SKIP to Section 8A	5

2.11 Within the past 12 months, where were you tested for HIV? [MARK ALL THAT APPLY]

Medical Settings		Non-Medical Settings
	Hospital or Clinic		Homeless Shelter
	STD/AIDS Clinic		An Outreach Program (e.g. syringe exchange programs, bars, health fair, bath houses.)
	Doctor’s Office		Mobile HIV Testing Unit (such as a van)
	Drug Treatment Facility		Jail or prison
	Mental Health Treatment Facility		Community-based organization
	Other:_____________________		Other:__________________________
	If yes to above DEFINE as “tested in medical setting.” Aim for a MAXIMUM of 2 in each group.		If yes to above DEFINE as “tested in non-medical setting.”
	If yes to both settings, DEFINE as “tested in non-medical setting”

2.12a The next question is about injecting, “shooting,” or “skin popping” drugs. This means injecting drugs with a needle or a syringe yourself or having someone who isn’t a health care provider inject you. Do not include hormones or drugs that were given or prescribed by a health care professional for things like allergies, diabetes, or HIV medications. Please remember your answer will be kept private. In the past twelve (12) months, have you injected drugs?

Yes  Continue	1
No  SKIP to 2.12c	2
Don’t know  Continue	3
Decline to answer  Continue	4

2.12b In the past 12 months, have you shared needles, syringes, or other injection equipment with someone else?

Yes	1
No	2
Don’t know	3
Decline to answer	4

[READ] For the purpose of these next couple questions, sex refers to either vaginal or anal sex. By vaginal sex, we mean when someone puts their penis into their partner’s vagina. By anal sex, we mean when someone inserts their penis into a partner’s butt.

2.12c In the past 12 months, have you had unprotected vaginal or anal sex with 2 or more partners? By unprotected sex, we mean any sex without a condom.

Yes	1
No	2
Don’t know	3
Decline to answer	4

2.12d. In the past 12 months, have you had unprotected vaginal or anal sex with a person who you knew or thought was HIV-positive? By unprotected sex, we mean any sex without a condom. [Note to screener: It does not matter if they knew at the time the partner was HIV+ or not.]

Yes	1
No	2
Don’t know	3
Decline to answer	4

DETERMINE IF ADOLESCENT MEETS RISK CRITERIA

• If respondent has injected drugs, shared injection equipment, had unprotected sex with 2 or more partners, and had unprotected sex with a person who may be HIV-positive, then ELIGIBLE (CONTINUE)

• If respondent has injected drugs and shared injection equipment or had unprotected sex with 2 or more partners or had unprotected sex with a person who may be HIV-positive, then ELIGIBLE (CONTINUE)

• If respondent has NOT injected drugs, shared injection equipment, had unprotected sex with 2 or more partners, NOR had unprotected sex with a person who may be HIV-positive, then INELIGIBLE SKIP to Section 8A

• If 2.12b, c, and d= “don’t know” or “decline to answer,” then INELIGIBLE SKIP to SectionA

2.13 Now I am going to ask you to describe your sexual identity. Would you describe yourself as [READ]:

Homosexual or “gay”	1
Bisexual	2
Heterosexual or “straight”	3
Questioning or unsure	4
Other (specify):_____________________________	5
Decline to answer	6

RECRUIT IF ELIGIBLE (based on answers to questions 2.12 a-d)

If 2.4a=1 (male) or 2 (female):

[ASK] Based on your answers, you are eligible to be in a focus group with other [males/females]. Is this okay with you?

	Yes  RECRUIT as POTENTIAL OR PAST HIV NEGATIVE/UNKNOWN ADOLESCENT. Segment by gender (Q 2.4). Skip to Section 9	1
INELIGIBLE	No  Skip to Section 8B	2
INELIGIBLE	Don’t know  Skip to Section 8B	3
INELIGIBLE	Decline to answer  Skip to Section 8B	4

If 2.4a=3 (transgender or transsexual):

[ASK] Based on your answers, you are eligible to be in a focus group with other people your age. Is this okay with you?

	Yes  Continue	1
INELIGIBLE	No   Skip to Section 8B	2
INELIGIBLE	Don’t know  Skip to Section 8B	3
INELIGIBLE	Decline to answer  Skip to Section 8B	4

[ASK] We will have two groups, one for males and one for females. Which group would you feel most comfortable in?

	Male  RECRUIT as adolescent. Segment as male POTENTIAL OR PAST HIV NEGATIVE/UNKNOWN ADOLESCENT. Skip to Section 9	1
	Female  RECRUIT as adolescent. Segment as female POTENTIAL OR PAST HIV NEGATIVE/UNKNOWN ADOLESCENT. Skip to Section 9	2
INELIGIBLE	Neither  Skip to Section 8B	3

Note to recruiter: Please aim to have a mix of adolescents who have: (1) never been tested or have not been tested in the past 5 years (i.e., potential client) and (2) been tested but are HIV negative or unknown.

SECTION 3

MTF TRANSGENDER

3.1 Have you ever been tested for HIV?

	Yes  Continue	1
	No  SKIP to 3.6a	2
INELIGIBLE	Don’t know  SKIP to Section 8A	3
INELIGIBLE	Decline to answer  SKIP to Section 8A	4

3.2. The next question is about the result of your HIV test. We are recruiting people who are positive and negative for the study. With that in mind, what was the result of your most recent HIV test? (Read options.)

	I tested positive for HIV  Continue	1
	I tested negative for HIV  SKIP to 3.4	2
	I did not get test results / Don’t Know  SKIP TO 3.4	3
INELIGIBLE	Decline to answer  SKIP to Section 8A	4

[IF MTF PAST CLIENT—HIV POSITIVE]

3.3 When did you first test positive? DATE (mm/dd/yy):__________

INELIGIBLE	More than 5 years ago  SKIP to Section 8A	1
	Within the past 5 years  Continue	2
INELIGIBLE	Don’t Know  SKIP to Section 8A	3
INELIGIBLE	Decline to answer  SKIP to Section 8A	4

3.4 Where did you first test positive? [Probe if more information is needed: “Tell me a little more about the place where the test was done.”]

Medical Settings		Non- Medical Settings
	Hospital or Clinic		Homeless Shelter
	STD/AIDS Clinic		An Outreach Program (e.g. syringe exchange programs, bars, health fair, bath houses.)
	Doctor’s Office		Mobile HIV Testing Unit (such as a van)
	Drug Treatment Facility		Jail or prison
	Mental Health Treatment Facility		Community-based organization
	Other:_____________________		Other:__________________________
	If yes to above DEFINE as “tested in medical setting” and continue. Aim for a MAXIMUM of 3 in each group.		If yes to above DEFINE as “tested in non-medical setting” and continue.

RECRUIT ELIGIBLE MTF PAST CLIENT—HIV POSITIVE

You are eligible to be in a group with other transgender persons who are also HIV positive. Is this okay with you?

	Yes  RECRUIT as MTF, HIV-positive past client. Skip to Section 9	1
INELIGIBLE	No  Skip to Section 8B	2
INELIGIBLE	Don’t know  Skip to Section 8B	3
INELIGIBLE	Decline to answer  Skip to Section 8B	4

[CONTINUE IF PAST CLIENT—HIV NEGATIVE/UKNOWN]

3.5 When was your last HIV test? DATE (mm/dd/yy):__________

	Five or more years ago  SKIP to 3.6a	1
	Within the past 12 months  CONTINUE	2
INELIGIBLE	Between 1 and 5 years ago  SKIP to Section 8A	3
INELIGIBLE	Don’t Know  SKIP to Section 8A	4
INELIGIBLE	Decline to answer  SKIP to Section 8A	5

3.6 Within the past 12 months, where were you tested for HIV? [MARK ALL THAT APPLY]

Medical Settings		Non- Medical Settings
	Hospital or Clinic		Homeless Shelter
	STD/AIDS Clinic		An Outreach Program (e.g. syringe exchange programs)
	Doctor’s Office		Mobile HIV Testing Unit (such as a van)
	Drug Treatment Facility		Jail or prison
	Mental Health Treatment Facility		Community-based organization
	Other:_____________________		Other:__________________________
If yes to above DEFINE as “tested in medical setting” and continue. Aim for a MAXIMUM of 3 per group.		If yes to above DEFINE as “tested in non-medical setting” and continue.
If yes to both settings, DEFINE as “tested in non-medical setting”

[CONTINUE IF POTENTIAL CLIENT OR PAST CLIENT—HIV NEGATIVE OR UNKNOWN]

3.7a The next question is about injecting, “shooting,” or “skin popping” drugs. This means injecting drugs with a needle or a syringe yourself or having someone who isn’t a health care provider inject you. Do not include hormones or drugs that were given or prescribed by a health care professional for things like allergies, diabetes, or HIV medications. Please remember your answer will be kept private. In the past twelve (12) months, have you injected drugs?

Yes	1
No	2
Don’t know	3
Decline to answer	4

3.7b. In the past 12 months, have you shared needles, syringes, or other injection equipment with someone else?

Yes	1
No	2
Don’t know	3
Decline to answer	4

[READ] For the purpose of these next couple questions, sex refers to either vaginal or anal sex. By vaginal sex, we mean when someone puts their penis into their partner’s vagina. By anal sex, we mean when someone inserts their penis into a partner’s butt.

3.7c. In the past 12 months, have you had unprotected vaginal or anal sex with 2 or more partners? By unprotected sex, we mean any sex without a condom.

Yes	1
No	2
Don’t know	3
Decline to answer	4

3.7e. In the past 12 months, have you had unprotected vaginal or anal sex with a person whom you knew or thought was HIV-positive? By unprotected sex, we mean any sex without a condom. [Note to screener: It does not matter if they knew at the time the partner was HIV+ or not.]

Yes	1
No	2
Don’t know	3
Decline to answer	4

DETERMINE IF MTF TRANSGENDER MEETS RISK CRITERIA

• If respondent has injected drugs, shared injection equipment, had unprotected sex with 2 or more partners, and had unprotected sex with a person who may be HIV-positive, then ELIGIBLE (CONTINUE)

• If respondent has injected drugs and shared injection equipment or had unprotected sex with 2 or more partners or had unprotected sex with a person who may be HIV-positive, then ELIGIBLE (CONTINUE to 2.13)

• If respondent has NOT injected drugs, shared injection equipment, had unprotected sex with 2 or more partners, NOR had unprotected sex with a person who may be HIV-positive, then INELIGIBLE (SKIP to Section 8A)

If 3.7c, d, and e= “don’t know” or “decline to answer,” then INELIGIBLE (SKIP to Section 8A)

RECRUIT IF ELIGIBLE (based on answers to questions 3.7a-e)

[ASK] You are eligible to be in a group with other transgender persons. Is this okay with you?

	Yes  RECRUIT as HIV NEGATIVE/UNKNOWN MTF. Segment as PAST CLIENT—HIV NEGATIVE/UNKNOWN or POTENTIAL CLIENT.* Skip to Section 9	1
INELIGIBLE	No  Skip to Section 8B	2
INELIGIBLE	Don’t know  Skip to Section 8B	3
INELIGIBLE	Decline to answer  Skip to Section 8B	4

*Potential Client if 3.1 = 2 or if 3.4 = 1; Past Client if 3.2 = 2

SECTION 4 INJECTION DRUG USER

4.1 Have you ever been tested for HIV?

	Yes  CONTINUE	1
	No  SKIP to 4.8a	2
INELIGIBLE	Don’t know  SKIP to Section 8A	3
INELIGIBLE	Decline to answer  SKIP to Section 8A	4

4.2 The next question is about the result of your HIV test. We are recruiting people who are positive and negative for the study. With that in mind, what was the result of your most recent HIV test? (Read options.)

	Yes  CONTINUE	1
	No  SKIP to 4.6	2
	Did not get test results / Don’t Know  SKIP to 4.6	3
INELIGIBLE	Decline to answer  SKIP to Section 8A	4

[IF HIV POSITIVE IDU]

4.3 When did you first test positive? DATE (mm/dd/yy):__________

INELIGIBLE	More than 5 years ago  SKIP to Section 8A	1
	Within the past 5 years  CONTINUE	2
INELIGIBLE	Don’t Know  SKIP to Section 8A	3
INELIGIBLE	Decline to answer  SKIP to Section 8A	4

4.4 Where did you first test positive? [Probe if more information is needed: “Tell me a little more about the place where the test was done.”]

Medical (HC) Settings		Non- Medical Settings
	Hospital or Clinic		Homeless Shelter
	STD/AIDS Clinic		An Outreach Program (e.g. syringe exchange programs, bars, health fair, bath houses.)
	Doctor’s Office		Mobile HIV Testing Unit (such as a van)
	Drug Treatment Facility		Jail or prison
	Mental Health Treatment Facility		Community-based organization
	Other:_____________________		Other:__________________________
	If yes to above DEFINE as “tested in HC setting” and continue. Aim for a MAXIMUM of 3 in each group.		If yes to above DEFINE as “tested in non-MEDICAL setting” and continue.

4.5 Now I am going to ask you to describe your sexual identity. Would you describe yourself as

READ:

Homosexual or “gay”	1
Bisexual	2
Heterosexual or “straight”	3
Questioning or unsure	4
Other (specify):_____________________________	5
Decline to answer	6

RECRUIT HIV POSITIVE IDU

You are eligible to be in a group with other people who are similar to you. Is this okay with you?

	Yes  RECRUIT as IDU, segment as HIV-positive past client (Attempt to have a minimum of 3 of each gender in group [see question 1.4a]) Skip to Section 9	1
INELIGIBLE	No  Skip to Section 8B	2
INELIGIBLE	Don’t know  Skip to Section 8B	3
INELIGIBLE	Decline to answer  Skip to Section 8B	4

[CONTINUE IF PAST CLIENT—HIV NEGATIVE OR UNKNOWN]

4.6 When were you last tested for HIV? DATE (mm/dd/yy):__________

	Five or more years ago  SKIP to 4.8a	1
	Within the past 12 months  CONTINUE	2
INELIGIBLE	Between 1 and 5 years ago  SKIP to Section 8A	3
INELIGIBLE	Don’t Know  SKIP to Section 8A	4
INELIGIBLE	Decline to answer  SKIP to Section 8A	5

4.7 Within the past 12 months, where were you tested for HIV? [MARK ALL THAT APPLY]

Medical Settings		Non- Medical Settings
	Hospital or Clinic		Homeless Shelter
	STD/AIDS Clinic		An Outreach Program (e.g. syringe exchange programs)
	Doctor’s Office		Mobile HIV Testing Unit (such as a van)
	Drug Treatment Facility		Jail or prison
	Mental Health Treatment Facility		Community-based organization
	Other:_____________________		Other:__________________________
If yes to above, DEFINE as “tested in MEDICAL setting” and continue. Aim for a MAXIMUM of 3 per group.		If yes to above, DEFINE as “tested in non-MEDICAL setting” and continue.
If yes to both settings, DEFINE as “tested in non-medical setting”

[CONTINUE IF POTENTIAL CLIENT OR PAST CLIENT—HIV NEGATIVE OR UNKNOWN]

4.8a In the past 12 months, have you shared needles, syringes, or other injection equipment with someone else?

Yes	1
No	2
Don’t know	3
Decline to answer	4

[READ] For the purpose of these next couple questions, sex refers to either vaginal or anal sex. By vaginal sex, we mean when someone puts their penis into their partner’s vagina. By anal sex, we mean when someone inserts their penis into a partner’s butt.

4.8b In the past 12 months, have you had unprotected vaginal or anal sex with 2 or more partners? By unprotected sex, we mean any sex without a condom.

Yes	1
No	2
Don’t know	3
Decline to answer	4

4.8c. In the past 12 months, have you had unprotected vaginal or anal sex with a person who you knew or thought was HIV-positive? By unprotected sex, we mean any sex without a condom. [Note to screener: It does not matter if they knew at the time the partner was HIV+ or not.]

Yes	1
No	2
Don’t know	3
Decline to answer	4

DETERMINE IF IDU MEETS RISK CRITERIA

• If respondent has shared injection equipment, had unprotected sex with 2 or more partners, and had unprotected sex with a person who may be HIV-positive, then ELIGIBLE (CONTINUE)

• If respondent has shared injection equipment or had unprotected sex with 2 or more partners or had unprotected sex with a person who may be HIV-positive, then ELIGIBLE (CONTINUE)

• If respondent has NOT shared injection equipment or had unprotected sex with 2 or more partners NOR had unprotected sex with a person who may be HIV-positive, then INELIGIBLE (SKIP to Section 8A)

• If 4.8a, b, and c= “don’t know” or “decline to answer,” then INELIGIBLE (SKIP to Section 8A)

4.9 Now I am going to ask you to describe your sexual identity. Would you describe yourself as

READ:

Homosexual or “gay”	1
Bisexual	2
Heterosexual or “straight”	3
Questioning or unsure	4
Other (specify):_____________________________	5
Decline to answer	6

RECRUIT IF ELIGIBLE (based on answers to questions 4.8a-c)

[ASK] You are eligible to be in a group with other people who are similar to you. Is this okay with you?

	Yes  RECRUIT as IDU, segment as HIV-negative/unknown past or potential client* (Attempt to have a minimum of 3 of each gender in group [see question 1.4a]) Skip to Section 9	1
INELIGIBLE	No  Skip to Section 8B	2
INELIGIBLE	Don’t know  Skip to Section 8B	3
INELIGIBLE	Decline to answer  Skip to Section 8B	4

*Potential Client if 4.1 = 2 or 4.6 = 1;

Past Client if 4.6 = 2

SECTION 5

POTENTIAL CLIENT

[READ] For the purpose of these next couple of questions, sex refers to either vaginal or anal sex. By vaginal sex, we mean when someone puts their penis into their partner’s vagina. By anal sex, we mean when someonen inserts their penis into a partner’s butt.

5.1a In the past 12 months, have you had unprotected vaginal or anal sex with 2 or more partners? By unprotected sex, we mean any sex without a condom.

Yes	1
No	2
Don’t know	3
Decline to answer	4

5.1b. In the past 12 months, have you had unprotected vaginal or anal sex with a person whom you knew or thought was HIV-positive? By unprotected sex, we mean any sex without a condom. [Note to screener: It does not matter if they knew at the time the partner was HIV+ or not.]

Yes	1
No	2
Don’t know	3
Decline to answer	4

DETERMINE IF POTENTIAL CLIENT MEETS RISK CRITERIA

• If respondent has had unprotected sex with 2 or more partners and/or had unprotected sex with a person who may be HIV-positive, then ELIGIBLE (CONTINUE)

• If respondent has NOT had unprotected sex with 2 or more partners or has not had unprotected sex with a person who may be HIV-positive, then INELIGIBLE (SKIP to Section 8A)

• If 5.1a and b=“don’t know” or “decline to answer,” then INELIGIBLE (SKIP to Section 8A)

RECRUIT IF ELIGIBLE (based on answers to questions 5.1a-b)

5.2a Now I am going to ask you to describe your sexual identity. Would you describe yourself as homosexual (or “gay”), bisexual, or heterosexual (or “straight”)?

	Homosexual or “gay” If respondent is male  SKIP TO 5.2b If respondent is female  SKIP TO 5.2e	1
	Bisexual If respondent is male  SKIP TO 5.2d If respondent is female  SKIP TO 5.2e	2
	Heterosexual or “straight” If respondent is male  SKIP TO 5.2c If respondent is female  SKIP TO 5.2e	3
	Other If respondent is male  SKIP TO 5.2d If respondent is female  SKIP TO 5.2e	4
	Questioning/Unsure If respondent is male  SKIP TO 5.2d If respondent is female  SKIP TO 5.2e	5
INELIGIBLE	Decline to answer  Skip to Section 8B	6

5.2b Based on your answers, you are eligible to be in our group with other men with similar sexual identity. Is this okay with you?

	Yes  RECRUIT as homosexual male, potential client. Skip to Section 9	1
INELIGIBLE	No  Skip to Section 8B	2
INELIGIBLE	Don’t know  Skip to Section 8B	3
INELIGIBLE	Decline to answer  Skip to Section 8B	4

5.2c Based on your answers, you are eligible to be in our group with other men with a similar sexual identity. Is this okay with you?

	Yes  RECRUIT as heterosexual male, potential client. Skip to Section 9	1
INELIGIBLE	No   Skip to Section 8B	2
INELIGIBLE	Don’t know  Skip to Section 8B	3
INELIGIBLE	Decline to answer  Skip to Section 8B	4

5.2d You are eligible to be in a group with either heterosexual “straight” men or with homosexual “gay” men. Which group would you prefer?

	Heterosexual or straight  RECRUIT as heterosexual male, potential client. Skip to Section 9	1
	Homosexual or gay  RECRUIT as MSM, potential client. Skip to Section 9	2
INELIGIBLE	Neither  Skip to Section 8B	3
INELIGIBLE	Don’t know  Skip to Section 8B	4
INELIGIBLE	Decline to answer  Skip to Section 8B	5

5.2e You are eligible to be in a group with other women, some of whom may be heterosexual or “straight.” Is this okay with you?

	Yes  RECRUIT as female, potential client. Skip to Section 9	1
INELIGIBLE	No  Skip to Section 8B	2
INELIGIBLE	Don’t know  Skip to Section 8B	3
INELIGIBLE	Decline to answer  Skip to Section 8B	4

SECTION 6

HIV-POSITIVE PAST CLIENT

6.1 Where did you first test positive? [Probe if more information is needed: “Tell me a little more about the place where the test was done.”]

Medical Settings		Non- Medical Settings
	Hospital or Clinic		Homeless Shelter
	STD/AIDS Clinic		An Outreach Program (e.g. syringe exchange programs, bars, health fair, bath houses.)
	Doctor’s Office		Mobile HIV Testing Unit (such as a van)
	Drug Treatment Facility		Jail or prison
	Mental Health Treatment Facility		Community-based organization
	Other:_____________________		Other:__________________________
	If yes to above DEFINE as “tested in medical setting” and continue. Aim for a MAXIMUM of 3 in each group.		If yes to above DEFINE as “tested in non-medical setting” and continue.

6.2. Now I am going to ask you to describe your sexual identity. Would you describe yourself as homosexual (or “gay”), bisexual, or heterosexual (or “straight”)?

	Homosexual or “gay” If respondent is male  SKIP TO 6.2b If respondent is female  SKIP TO 6.2e	1
	“Bisexual” If respondent is male  SKIP TO 6.2d If respondent is female  SKIP TO 6.2e	2
	Heterosexual or “straight” If respondent is male  SKIP TO 6.2c If respondent is female  SKIP TO 6.2e	3
	Other If respondent is male  SKIP TO 6.2d If respondent is female  SKIP TO 6.2e	4
	Questioning/Unsure If respondent is male  SKIP TO 6.2d If respondent is female  SKIP TO 6.2e	5
INELIGIBLE	Decline to answer  Skip to Section 8B	6

6.2b Based on your answers, you are eligible to be in a group with others who have the same sexual identity and HIV status. Is this okay with you?

	Yes  RECRUIT as MSM, HIV-positive past client. Skip to Section 9	1
INELIGIBLE	No  Skip to Section 8B	2
INELIGIBLE	Don’t know  Skip to Section 8B	3
INELIGIBLE	Decline to answer  Skip to Section 8B	4

6.2c Based on your answers, you are eligible to be in a group with others who have the same sexual identity and HIV status. Is this okay with you?

	Yes  RECRUIT as heterosexual male, HIV-positive past client. Skip to Section 9	1
INELIGIBLE	No  Skip to Section 8B	2
INELIGIBLE	Don’t know  Skip to Section 8B	3
INELIGIBLE	Decline to answer  Skip to Section 8B	4

6.2d You are eligible to be in a group with either heterosexual “straight” men or with homosexual “gay” men with a similar HIV status as you. The option is your’s. Which group would you prefer to be in?

	Heterosexual or straight  RECRUIT as heterosexual male, HIV-positive past client. Skip to Section 9	1
	Homosexual or gay  RECRUIT as MSM, HIV-positive past client. Skip to Section 9	2
INELIGIBLE	Neither  Skip to Section 8B	3
INELIGIBLE	Don’t know  Skip to Section 8B	4
INELIGIBLE	Decline to answer  Skip to Section 8B	5

6.2e You are eligible to be in a group with other women, some of whom may be heterosexual or “straight” and have a similar HIV status as you. Is this okay with you?

	Yes  RECRUIT as female, HIV-positive past client. Skip to Section 9	1
INELIGIBLE	No  Skip to Section 8B	2
INELIGIBLE	Don’t know  Skip to Section 8B	3
INELIGIBLE	Decline to answer  Skip to Section 8B	4

SECTION 7

HIV-NEGATIVE OR UNKNOWN PAST CLIENT

7.1 Within the past 12 months, where have you had your HIV test(s)? [MARK ALL THAT APPLY] [Probe if more information is needed: “Tell me a little more about the place where the test was done.”]

Medical Settings		Non- Medical Settings
	Hospital or Clinic		Homeless Shelter
	STD/AIDS Clinic		An Outreach Program (e.g. syringe exchange programs, bars, health fair, bath houses.)
	Doctor’s Office		Mobile HIV Testing Unit (such as a van)
	Drug Treatment Facility		Jail or prison
	Mental Health Treatment Facility		Community-based organization
	Other:_____________________		Other:__________________________
	If yes to any above DEFINE as “tested in medical setting” and continue. Aim for a MAXIMUM of 3 in each group.		If yes to any above DEFINE as “tested in non-medical setting” and continue.
If yes to both settings, DEFINE as “tested in non-medical setting” and continue.

[READ] For the purpose of these next couple of questions, sex refers to either vaginal or anal sex. By vaginal sex, we mean when someone puts their penis into their partner’s vagina. By anal sex, we mean when someonen inserts their penis into a partner’s butt.

7.2a In the past 12 months, have you had unprotected vaginal or anal sex with 2 or more partners? By unprotected sex, we mean any sex without a condom.

Yes	1
No	2
Don’t know	3
Decline to answer	4

7.2b In the past 12 months, have you had unprotected vaginal or anal sex with a person who you knew or thought was HIV-positive? By unprotected sex, we mean any sex without a condom. [Note to screener: It does not matter if they knew at the time the partner was HIV+ or not.]

Yes	1
No	2
Don’t know	3
Decline to answer	4

DETERMINE IF HIV-NEGATIVE/UNKNOWN MEETS RISK CRITERIA

• If respondent has had unprotected sex with 2 or more partners and/or had unprotected sex with a person who may be HIV-positive, then ELIGIBLE (CONTINUE)

• If respondent has NOT had unprotected sex with 2 or more partners or has not had unprotected sex with a person who may be HIV-positive, then INELIGIBLE (SKIP to Section 8A)

• If 8.2a and b= “don’t know” or “decline to answer,” then INELIGIBLE (SKIP to Section 8A)

7.3a. Now I am going to ask you to describe your sexual identity. Would you describe yourself as:

	Homosexual or “gay” If respondent is male  SKIP TO 73b If respondent is female  SKIP TO 8.3e	1
	“Bisexual” If respondent is male  SKIP TO 7.3d If respondent is female  SKIP TO 7.3e	2
	Heterosexual or “straight” If respondent is male  SKIP TO 7.3c If respondent is female  SKIP TO 7.3e	3
	Other If respondent is male  SKIP TO 7.3d If respondent is female  SKIP TO 7.3e	4
	Questioning/Unsure If respondent is male  SKIP TO 7.3d If respondent is female  SKIP TO 7.3e	5
INELIGIBLE	Decline to answer  Skip to Section 8	6

7.3b Based on your answers, you are eligible to be in our group with others who have a similar sexual identity. Is this okay with you?

	Yes  RECRUIT as MSM, HIV-negative or unknown past client. Skip to Section 9	1
INELIGIBLE	No  Skip to Section 8B	2
INELIGIBLE	Don’t know  Skip to Section 8B	3
INELIGIBLE	Decline to answer  Skip to Section 8B	4

7.3c Based on your answers, you are eligible to be in our group with other heterosexual or “straight” men. Is this okay with you?

	Yes  RECRUIT as heterosexual male, HIV-negative or unknown past client. Skip to Section 9	1
INELIGIBLE	No  Skip to Section 8B	2
INELIGIBLE	Don’t know  Skip to Section 8B	3
INELIGIBLE	Decline to answer  Skip to Section 8B	4

7.3d You are eligible to be in a group with either heterosexual “straight” men or with homosexual “gay” men. The option is your’s. Which group would you prefer to be in?

	Heterosexual or straight  RECRUIT as heterosexual male, HIV-negative or unknown past client. Skip to Section 9	1
	Homosexual or gay  RECRUIT as MSM, HIV-negative or unknown past client. Skip to Section 9	2
INELIGIBLE	Neither  Skip to Section 8B	3
INELIGIBLE	Don’t know  Skip to Section 8B	4
INELIGIBLE	Decline to answer  Skip to Section 8B	5

7.3e You are eligible to be in a group with other women, some of whom may be heterosexual or “straight.” Is this okay with you?

	Yes  RECRUIT as female, HIV-negative or unknown past client. Skip to Section 9	1
INELIGIBLE	No  Skip to Section 8B	2
INELIGIBLE	Don’t know  Skip to Section 8B	3
INELIGIBLE	Decline to answer  Skip to Section 8B	4

SECTION 8
CLOSING FOR INELIGIBLE PERSONS

SECTION 8A

The following questions will be asked of all ineligible persons before terminating the call.

8.1. In the last year, have you participated in an HIV prevention intervention?

Yes  Continue	1
No  Continue	2
Don’t Know  Continue	3
Decline to answer  Continue	4

8.2. In the last three years, have you ever smoked on a daily basis?

Yes  Continue	1
No  Continue	2
Don’t Know  Continue	3
Decline to answer  Continue	4

8.3. On average, do you drink at least one alcoholic beverage such as wine, beer or hard liquor per day?

Yes  Continue	1
No  Continue	2
Don’t Know  Continue	3
Decline to answer  Continue	4

READ: “Thank you very much for taking the time to answer my questions. However, you do not meet the eligibility criteria for a focus group. The criteria to participate were decided earlier by the project leaders. Thank you for being willing to help us.

We believe that it is important for everyone to protect themselves and their partners from HIV and other sexually transmitted infections. If you have any questions or if you want to learn more about HIV you can call the CDC Information Hotline at 1-800-CDC-INFO (1-800-232-4636) or if you have access to the internet you can go online to www.cdc.gov.”

SECTION 8B

READ: “Thank you very much for taking the time to answer my questions. However, because you do not accept the focus group assignment, we cannot invite you to participate. Thank you for being willing to help us.

We believe that it is important for everyone to protect themselves and their partners from HIV and other sexually transmitted infections. If you have any questions or if you want to learn more about HIV you can call the CDC Information Hotline at 1-800-CDC-INFO (1-800-232-4636) or if you have access to the internet you can go online to www.cdc.gov.”

SECTION 9

INVITATION FOR ELIGIBLE PARTICIPANTS

READ: “We want to invite you to be in a focus group about HIV testing services. You will get together for about 2 hours to talk about your thoughts on the HIV testing process. You will be in a group of 9-12 other people with the same HIV status as you. We will be audio-taping the group.

If you choose to attend, whatever you say will be kept private. Before the focus group, we will ask all members to keep what is said private. If you feel more comfortable, you can choose to use a false name or alias within the group. You will be given $50 to for your time and effort. If 3 or fewer people come to the scheduled focus group, we will not conduct the FG. However, you will be given $15 for travel costs.

In a minute, I will need to ask you for your first name and phone number so that we can call to remind you about the appointment. This information is necessary for you to join. I will also ask you for your last name, postal, or email address so that we can send you directions to the location. However, telling me your last name and addresses are not necessary to join. Finally, I will also ask the month and year of your birth to help us keep track of who attends the groups. This information is also necessary. All of your contact information will be destroyed immediately after the FG.”

READ: May I schedule you to come?

Yes	Confirm the date and time of the group, and give the address of and directions to the facility. Read: If you arrive more than 30 minutes late to the focus group, you will not be able to participate.
No	READ: “If you decide that you want to attend, please call us at [insert phone number]. Thank you for your time.”
Don’t Know / Not Sure / Declines to answer	READ: “If you decide that you want to attend, please call us at [insert phone number]. Thank you for your time.”

READ: “In order for us to check you in when you arrive for your appointment, you will be asked your first name and date of birth. May I have your first name and your date of birth—only month and year?”

FIRST NAME: _____________________________________________________________

BIRTH MONTH/YEAR: _______________________________________________

READ: “A day or so before your appointment, we will call you to re-confirm the time. We will need your phone number to do this. What is the best time to reach you? What is the best telephone number to reach you at that time?”

BEST TIME TO BE REACHED: _______________________________________________

BEST PHONE NUMBER: ________________

READ: “Is there another time and number we can try if we miss you?”

ALTERNATE TIME TO BE REACHED:_________________________________________

• ALTERNATE PHONE NUMBER: ___

READ: Can we leave a message? We will not leave any details in the message, but will remind you of the appointment and ask you to call us back to confirm.” __ Yes ____No____

***WITHOUT A PHONE NUMBER—PERSON DOES NOT QUALIFY***.

READ: “We would also like to be able to send you a reminder letter or e-mail with directions.  What is your mailing address or E-mail address? We will never send you anything other than the reminder and directions.”

NAME (only necessary when using postal address) : ____

ADDRESS: ____________________

ZIP CODE:

E-MAIL ADDRESS: __________________

FOR HIV POSITIVE PARTICIPANTS: Remind them that they will need to bring documentation of their HIV status.

• READ: “Your participation in this project is very important. If for some reason you will not be able to attend, please let us know right away. You can call us anytime at [insert phone number], and if we are not here, please leave a message. Thank you.”

To be completed by recruiter
Eligible and scheduled – NOTE GROUP NAME/TIME/DATE	YES	NO
Eligible, but not scheduled: NOTE REASON	YES	NO
Eligible, but refused to participate: NOTE REASON	YES	NO
Ineligible	YES	NO

35