Screening Form (NYBC)

HIV/AIDS Risk Reduction Interventions for African-American

Heterosexual Men

0920-10CM

Attachment 3b

Data Collection: Screening Form – NYBC

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

HIV/AIDS Risk Reduction Interventions for African-American

Heterosexual Men: Data Collection: Screening Form – NYBC (Attachment 3b)

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 persons 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 (0920-09XX)

Participant Screening Form

Date:	Recruiter ID:
Screening ID:	Eligibility Status: No Yes

Script: "Hi. I work with STRAIGHT TALK, a research program focused on African American men who have sex only with women and their health, relationships, and sexual behavior and HIV prevention. Can I ask you a few questions? It will only take a minute or two. Some of the questions are personal, including questions about sexual activity. Your involvement is voluntary, your responses will be kept private, and you can refuse to answer a question or stop at any time. The information you give us will be combined with everybody else’s information so that collectively – not individually – we can describe the group involved in the study. Are you interested? If you are eligible and decide to participate, you will have the opportunity to receive $25 for an initial visit, $25 each group session and $40 for a follow-up survey, as a token of appreciation. In addition, you will receive a $4 MetroCard for each visit to the site.”

1. What is your month and year of birth (mm/yy)? _______________

[must be at least 18]

2. What is your gender?

Male

Female

3. What is your race/ethnicity?

Race (check only one box):

-- American Indian or Alaska Native

-- Asian

-- Black or African American

-- Native Hawaiian or Other Pacific Islander

-- White

Ethnicity (check only one box):

-- Hispanic or Latino

-- Not Hispanic or Latino

4. Do you understand, and are you comfortable speaking and reading English?

No

Yes

5. How did you find out about the study? (Select based on participant response. If participant provides two answers, find out which source really had him call.)

Street outreach: _____________________

Brochure/flyer: _____________________

Press/newspaper: ________________

Gym: ________________________

Bar outreach: ____________________

Park outreach: ______________________

Primary care clinic: _____________________

Counseling and testing program: _____________________

Substance use/abuse counselor/program: ___________________

Community based organization/agency: ______________________

Snowball: __________________________

Previous study: _____________________

Other, specify: _________________________

6. Do you live in the New York City area?

No

Yes Are you a resident of the either the South Bronx or Harlem?

No

Yes

7. Which of the following best describes where you currently live?

Rent or own an apartment or house (alone or with others)

Stay at family’s/friends’ home temporarily

Residential/single room occupancy hotel

Shelter or emergency housing

HIV/AIDS housing/group home/other form of assisted living

Drug or other health treatment facility

Homeless

Other (SPECIFY) __________________________________________________

8. What is the highest level of education that you completed?

8^TH GRADE OR LESS

SOME HIGH SCHOOL (GRADES 9-11)

HIGH SCHOOL GRADUATE OR GED

SOME COLLEGE/TECHNICAL SCHOOL (1-3 YEARS)

COLLEGE GRADUATE

ADVANCED DEGREE

9. Have you ever tested for HIV infection?

No

Yes What was your most recent result?

Negative

Positive

Don’t know

10. In the past 3 months, how many women have you had vaginal or anal sex with?

None

One

Two

Three or more

11. Think of the women you had vaginal or anal sex with in the last 3 months. How many of those women did you have unprotected sex (meaning any penetration without a condom)?

None [If Q.11 is 1 or 2 then LOW RISK]

One [If Q.11 is 1 or 2 then LOW RISK]

Two or more [HIGH RISK]

12. In the past 5 years, how many men have you had oral or anal sex with (insertive or receptive)?

None

One

Two or more

13. Have you injected drugs in the last 3 years?

No

Yes When was the last time?

Date: ____________

14. What research studies have you participated in the last 6 months?

None

Intervention exclusionary study (HIV or substance use or formative phase of STRAIGHT TALK)

Screener may have to probe a bit using local study name jargon or descriptions of studies currently being conducted at the site if respondent is unsure. Also, screener may probe for other interventions known by site staff that may affect study outcomes.

[Any answer other than none is exclusionary]

For those who are eligible on full screening:

“You are eligible to participate in the study. Over the next few months, we will be conducting a study about African American men’s health, relationships, and sexual behavior and HIV prevention. There will be an initial visit with a risk assessment. You would then be schedule for the first of 4 group sessions. There would be one final individual visit after the group sessions. You can receive a token of appreciation of $25 for the initial visit, $25 for each group session and $40 for the follow-up visit. In addition, you can receive a $4 MetroCard for each visit to the site.

If you arrive at the first visit too late to complete the process in the time allotted, you will not receive compensation. If possible, you will be rescheduled for another time.

If not enough people show up for the first group session, you will receive a token of appreciation of $15 in cash and a two-way MetroCard and you will be rescheduled. If too many people show up for the first group session, you may also receive $15 in cash and a two-way MetroCard and, if possible be rescheduled.

.

For those who are ineligible on full screening:

“I’m sorry but you are not eligible to participate in this study at this time. There are many reasons why people are not eligible to be in the study, reasons that were decided earlier by the researchers. We appreciate your interest in this study and willingness to consider helping to improve HIV prevention programs in our community. Thank you.”

Inclusion/exclusion criteria:

• 18-45 years of age

• Resident of South Bronx and Harlem communities

• Male

• Understand and read English

• Self-identify as African American, Black, Caribbean Black or multiethnic Black

• Self report as HIV negative or unknown status

• Report unprotected vaginal or anal intercourse with 2 or more female partners in past 3 months

• No injection drug use in the last 3 years

• No reported oral or anal sex with a man in the past 5 years

• Not participated in any HIV or substance use prevention studies in last 6 months

• Did not participate in the Phase 1 formative research

Screener Contact Card

Contact Form
All information provided is private to the extent permitted by law. Please print.
Name: ____________________________________________________________________
Address: ____________________________________________________________________
City: ___________________________			State: ____________					Zip: ______________
Home Phone ___________________________			OK to leave message?					 Yes		 No
Other Phone ___________________________				Best time to call __________________________
E-Mail Address: ______________________________________________________					OK to leave message?		 Yes		 No
Sex:	 Male		 Female
Race (check only one box):	 Black or African American		 American Indian/Alaska Native					 Asian
	 White		 Native Hawaiian or Other Pacific Islander
Ethnicity (check only one box):			 Hispanic or Latino  Not Hispanic or Latino
I consent to STRAIGHT TALK contacting me in regards to participation in their research study. __________________________________(Signature)
Office Use Only:	Vaccine Trial_______		Other________
Staff: _________________		Date _________________				Location: _________________