AA STD Disparities - Triad and Interview Screener

African American STD Disparities Health Communication Project

#0920-0798

Attachment 9

Triad And Interview Screener Form

(Phases 1 & 2)

Form Approved

OMB No. 0920-0798

Expiration Date: 01/31/2011

Screening Instrument

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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0798).

ASK TO SPEAK TO A FEMALE OR MALE IN THE HOUSEHOLD WHO IS 18-45 YEARS OLD

Introduction

Hello, my name is _______________ and I’m from (name of company). I am calling on behalf of RTI International, a non-profit research organization, and the Centers for Disease Control and Prevention (or CDC).

I am not selling or promoting any product. I am calling to invite men and women in your area to take part in a research study about sexual health, Sexually Transmitted Diseases (STDs) and HIV and how these things impact people and communities.

For Triads: The discussions will involve a group of up to 3 people plus a moderator.

For Interviews: The interviews will be conducted one-on-one.

We are looking for sexually active adults between the ages of 18-45. Your opinions are important to us and will help to contribute to the CDC’s efforts to reduce STDs. If you are eligible and choose to be [in the group, you will receive $50] OR [interviewed, you will receive $50] as a thank you for your time and effort and to help reimburse you for your travel expenses.

To see if you are eligible for this study, I need to ask you some personal questions, including a couple questions about your sexual behavior. It is your choice to answer these questions. Your answers will be kept private. You can refuse to answer any question or stop at any time.

If you are not eligible and/or choose not to be part of the study, all responses you give to me today will be destroyed and you will not be contacted again.

My questions will only take a few minutes. May I ask you the questions now?

Yes..................1 Continue

No...................2 End

Procedures for Recording and Limiting Information:

• Only record information for the questions in the screener

• If an informant reveals additional personal information, thank them for being helpful, but guide them back to the questions-“That is interesting to learn, but can I now ask you about. . . “

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

Male	1	[RECORD and SEE QUOTA]
Female	2
Transgender or Transsexual	3	[NOT ELIGIBLE –SKIP TO Q 10]
Refused	4

2. How old are you?

_______________

Under 18 years old	1	[NOT ELIGIBLE - THANK & END]
18 – 29	2	[SEE QUOTA]
30 – 45	3
46 years old or older	5	[NOT ELIGIBLE – SKIP TO Q 10]
Refused	6

3. What is the category that best describes your ethnic background?

Not Hispanic or Latino	1	Continue
Hispanic or Latino	2	[NOT ELIGIBLE – SKIP TO Q 10]

4. What is the category that best describes your racial background?

American Indian or Alaska Native	1	[Not eligible – skip to q 10]
Asian	2
Black or African American	3	Continue
Native Hawaiian or Other Pacific Islander	4	[Not eligible – skip to q 10]
White	5

5. Now I’m going to ask you to describe your sexual identity. Would you describe yourself as…

Heterosexual or straight	1	Continue
Homosexual, gay or same-gender loving	2	[Not eligible – skip to q 10]
Bisexual	3

Now I’m going to ask you a question about your sexual activity. Your answer will be kept completely confidential.

6. Within the past 6 months, have you had sexual intercourse (or sex) with another person?

Yes	1	Continue
No	2	[not eligible – skip to q 10]

7. Do you or does anyone else in your immediate family or household work… [READ LIST.]

In marketing research?	1	[not eligible – skip to q 10]
In marketing or advertising?	2
In public health or healthcare?	3
None	4

8. Have you participated in a focus group or interview in the last 6-months? [EXPLAIN WHAT IS MEANT BY A FOCUS GROUP OR AN INTERVIEW]

Yes	1	[GO TO Q8]
No	2	[SKIP TO Q9]

9. What was/were the topics discussed?

[IF PARTICIPATED IN AN INTERVIEW ABOUT SOCIAL OR PUBLIC HEALTH ISSUE, SEXUAL HEALTH, SEXUALLY TRANSMITTED DISEASES, or HIV/AIDS IN THE PAST 6 MONTHS, NOT ELIGIBLE – SKIP TO Q 10]

10. What is your current marital status? Are you…? [READ LIST]

Single	1	[RECORD]
Divorced or Widowed	2
Married	3
Refused	4

11. What is the highest level of education you have completed?

[READ LIST IF NECESSARY]

Primary or Middle School (grade school)	1	[RECORD]
Some high school, but not a graduate	2
High school graduate (or GED)	3
Some college/technical, not graduate	4
College graduate or higher	5
Refused	6

12. What is your yearly household income? This includes only your income and not a combined household income. [READ LIST IF NECESSARY]

Less than $20,000	1	[RECORD]
$20,000-$39,999	2
$40,000-$59,999	3
$60,000-$69,000	4
$70,000-$79,000	5
$80,000 or above	6
Don’t know	7

13. How many months or years have you lived in the community where you currently live? _______

14. Do you feel like you are a part of the community where you currently live?

Yes	1
No	2

[IF INELIGIBLE – CONTINUE WITH CLOSING FOR INELIGIBLES]

[IF ELIGIBLE - SKIP TO INVITATION]

Closing for Ineligible Participants:

Thank you for answering all of my questions. Unfortunately, you are not eligible to be in this study. There are many possible reasons why people may not be eligible for the study. These reasons were decided earlier by the researchers. We value your interest in this research study. Thank you for being willing to help us.

Invitation:

As I mentioned, we will be talking to women/men about their opinions on Sexually Transmitted Diseases (STDs) and their impact on people and communities. We would like to invite you to take part in a discussion, either individually or as part of a group of up to 2 other people plus a moderator.

The group discussion/interview will last about [1.5 hours OR 1 hour]. You will not be asked to buy anything. During the group, we’ll cover sexual health topics, including STDs and HIV. You will be asked your first name only, but can choose to use a made-up name if you prefer. You will be contacted a day or two before the discussion as a reminder. Everything you tell us will be kept private. We will not share your information with anyone outside the study, and your name will not appear in any report.

We’re simply interested in your opinions. But if you begin to feel uncomfortable at any time, you can refuse to answer questions or leave the discussion. Your participation in this study poses no physical risks to you.

If you have questions about your rights as a participant, call the CDC at 1-800-584-8814. Leave a message with your name and phone number, and someone will call you back as soon as possible.

15. For participating in the group/interview, you will receive an honorarium of [$50] for your time and effort and to help with your travel expenses. Will you be able to join us?

Yes	1	[CONTINUE]
No (Refuse to participate)	2	[THANK AND END]

[READ THE FOLLOWING STATEMENTS]

“We will be audiotaping the group/interview and some project staff from CDC may be observing the group/interview. In order to participate in the [group/interview], you must agree to be audiotaped and allow staff from the CDC to observe. As I said, if you choose to attend, whatever you say will be kept private. In the group discussions, we will ask all other group members to keep what is said private. We will never link your name with any comment you make in any report that we write.”

“If you need to wear glasses either for reading or watching TV, please bring them with you to the [group/interview].”

“Also, we need to let you know that there will not be any childcare provided at the facility, so please make the appropriate childcare arrangements if you have children.”

Participant Information

Interviewer: ________

Date: ________

Letter sent: ________

Reconfirmation: ________

Call

NAME: _________________________________________________

ADDRESS: _________________________________________________

CITY: _________________________________________________

ZIP CODE: _________________________________________________

Phone: Day___________________ Evening __________________

EMAIL _________________________________________________

What is the best time to reach you? What is the best telephone number to reach you at that time? If you do not answer, may we leave a private message at that number?

BEST TIME TO BE REACHED:

BEST PHONE NUMBER:

Is there another time and number we can try if we miss you?

ALTERNATE PHONE NUMBER:

Your participation in this study 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 there, please leave a message. Thank you.