Message Testing - Survey screener

Formative Research and Tool Development

OMB No. 0920-0840, Expiration 31 January 2013

Title of Sub-collection:

Development of HIV Prevention Decision Support Messages for Men Who Have Sex with Men and Heterosexuals

Attachment 6

Screener/ Web-based Survey

Contact Person:

Donata Green, PhD

1600 Clifton Rd. NE

Mailstop E-49

Atlanta, GA 30329

Telephone: (404) 639-3869

Fax: (404) 639-2007

E-mail: dqg7@cdc.gov

Form Approved

OMB No. 0920-0840

Expiration Date 01/31/2013

Development of HIV Prevention Decision Support Messages for Men Who Have Sex with Men and Heterosexuals

Screener /Web-based Survey

Public reporting burden of this collection of information is estimated to average 2 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 (0920-0840)

Development of HIV Prevention Decision Support Messages

for Men Who Have Sex with Men and Heterosexuals

(OMB No. 0920-0840, Expiration 31 January 2013)

Field Testing Web-based Survey

Recruitment Screener

We are asking people to be in a research study that will help us learn more about what people think about HIV prevention messages. RTI, a research company in North Carolina, and [insert survey vendor name and location here] are doing the study. The Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia is funding the research.

To see if you are a good match for this study, we will need to ask you some personal questions. Some of the questions will be about the types of sex you have and your HIV status, if you know it. It is your choice to answer the questions. Your answers will be kept private to the extent allowed by law. You can refuse to answer any question or stop at any time.

May we ask you the questions to see if this you are a good match for this study?

            Yes                       CONTINUE

            No                        TERMINATE

QUESTIONS…

Background Information

1. How old are you?

Age__________ [TERMINATE IF UNDER 18]

1. Don’t know [Terminate]

2. Refuse to answer [TERMINATE IF VERIFICATION OF 18 OR OLDER IS NOT POSSIBLE]

2. What is your gender?

1. Male

2. Female

3. Transgender or Transsexual

4. Other [Specify: ] [Terminate]

5. Don’t know [Terminate]

6. Refuse to answer [Terminate]

3. Which do you consider yourself to be?

1. Gay, homosexual, lesbian, or same gender loving

2. Bisexual or two spirited

3. Straight or heterosexual

4. Other [Specify: ] [Terminate]

5. None of the above/unsure [Terminate]

6. Don’t know [Terminate]

7. Refuse to answer [Terminate]

4. What is your current relationship status? Are you…? [If a participant identifies herself as a woman and says that she is in a relationship or married to a woman, she would be terminated.]

1. Single

2. Married to a man

3. Married to a woman

4. In a relationship with a man

5. In a relationship with a woman

6. Divorced or widowed

7. Don’t know

8. Refuse to answer

5. Are you of Hispanic or Latino origin? [recruit mix]

1. Yes

2. No

3. Don’t know

4. Refuse to answer

6. Which of the following best describes your race? [recruit mix]

1. White

2. Black or African American

3. Asian

4. Native Hawaiian or Other Pacific Islander

5. American Indian or Alaska Native

6. Other race [Specify: ]

7. Don’t know

8. Refuse to answer

7. What is the highest grade or year of school you finished?

1. Never attended school or only attended kindergarten

2. Grades 1 through 8 (elementary)

3. Some high school

4. High school graduate (includes GED)

5. Some college or technical school

6. College or technical school graduate

7. Don’t know

8. Refuse to answer

8. Which best describes your total personal income during the past year?

1. Less than $21,000

2. $21,000 to $30,000

3. $31,000 to $40,000

4. $41,000 to $50,000

5. $51,000 or more

6. Don’t know

7. Refuse to answer

9. What is your zip code?

1. Please fill in:__________________

10. Have you ever been tested for HIV?

    1. Yes

    2. No

    3. Don’t know

    4. Decline to answer

11. 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.)

    1. I tested positive for HIV

    2. I tested negative for HIV

    3. My results were unclear / Don’t Know

    4. I never got my results

    5. Decline to answer

11a. [If positive] When did you first test positive? DATE (mm/dd/yy):__________

1. More than 5 years ago

2. 5 or less years ago

3. Don’t Know

4. Decline to answer

11b. [If negative or unknown] When was your last HIV test?

5. Three or more years ago

6. Within the past 12 months

7. Between 1 and 3 years ago

8. Don’t Know

9. Decline to answer

High-Risk Behaviors

12. Did you have [oral/vaginal/anal] sex with any of your [female/male] partner(s) in the past [INSERT TIME FRAME]?

1. Yes

2. No

3. Don’t know

4. Refuse to answer

13. How often did you and your partners use a condom in the past [INSERT TIME FRAME]?

1. Never

2. Occasionally

3. Usually

4. Always

5. Don’t know

6. Refuse to answer

14. In the past 12 months, did you have unprotected oral, vaginal, or anal sex with any non-main partners – that is, somebody who you  did not consider to be a spouse, significant other, or life partner ? 

1. Yes

2. No

3. Don’t know

4. Decline to answer

15. 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.]

    1. Yes

    2. No

    3. Don’t know

    4. Decline to answer

16. In the past 12 months, have you had unprotected vaginal or anal sex with a person whose HIV status you did not know? By unprotected sex, we mean any sex without a condom.

1. Yes

2. No

3. Don’t know

4. Decline to answer

17. 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?

1. Yes

2. No

3. Don’t know

4. Decline to answer

Invitation:

Thank you for answering these questions. This survey is part of a research study on behalf of the Centers for Disease Control and Prevention (CDC) regarding safe sexual behaviors and we would like to hear your views. As a token of appreciation, you will receive $25 [INSERT METHOD OF PAYMENT AND DATE]. This is an important research effort and we appreciate your assistance.

Closing for Ineligible Participants:

Thank you for answering all of the questions. You are not eligible to be in this study because you did not meet our eligibility criteria. We value your interest in this research study. Thank you for being willing to help us.

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