Form 3c Screener for One-on-One Surveys

“Promoting HIV testing among low income heterosexual young adult

Black men”

0920-XXXX

Attachment 3c. Phase 2 Screener for One-on-One Surveys

Form Approved

OMB No. 0920-XXXX

Expiration Date XX/XX/20XX

“Promoting HIV Testing among Low Income Heterosexual Young Adult Black Men”

Screener for One-on-One Surveys

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-XXXX)

SCREENING TOOL

Hello my name is [insert name here] and I am from the ‘BEATS’ project sponsored by St. John’s University and the Centers for Disease Control and Prevention (CDC). We are conducting surveys to get more information on how we can develop better health programs. We are looking to meet the specific needs of young Black men who have been arrested or incarcerated. The survey will take about 30 minutes to complete and those that complete the survey will receive a $25 gift certificate. The survey is anonymous, meaning your name will not be used and no one, including the staff at Fortune Society or your parole/probation officer, will know what responses you provided.

Are you interested in participating?

If no,

We appreciate you speaking with us. If you should change your mind and decide to participate in the survey, feel free to contact our study office at

XXX-XXXX[GIVE STUDY FLIER]

If yes,

We are looking to capture the opinions of a very specific group so; I am going to make sure you meet our eligibility requirements for the study.

How old are you?

If >18 or <25

Thank you for your interest in the survey. Unfortunately you do not fall within criteria for the study. Please understand that our selection criteria is not a reflection of you personally, but a result of the needs and requirements of the study. We appreciate the time you gave.

If 18-25

Go to question X.

Have you been arrested or released from jail/prison within the past year?

If no

Thank you for your interest in the survey. Unfortunately you do not fall within criteria for the study. Please understand that our selection criteria is not a reflection of you personally, but a result of the needs and requirements of the study. We appreciate the time you gave.

If yes

Go to question X.

Do you consider yourself Black?

If no

Thank you for your interest in the survey. Unfortunately you do not fall within criteria for the study. Please understand that our selection criteria is not a reflection of you personally, but a result of the needs and requirements of the study. We appreciate the time you gave.

If yes

Go to question X.

Have you been sexually active with a woman within the past 6 months?

If no

Thank you for your interest in the survey. Unfortunately you do not fall within criteria for the study. Please understand that our selection criteria is not a reflection of you personally, but a result of the needs and requirements of the study. We appreciate the time you gave.

If yes

Go to question X.

What city do you live in?

If outside NYC

Thank you for your interest in the survey. Unfortunately you do not fall within criteria for the study. Please understand that our selection criteria is not a reflection of you personally, but a result of the needs and requirements of the study. We appreciate the time you gave.

If NYC

Go to question X.

Are you a non-Hispanic heterosexual man who is HIV-negative or status unknown who has not been arrested for a sexual offense?

If no

Thank you for your interest in the survey. Unfortunately you do not fall within criteria for the study. Please understand that our selection criteria is not a reflection of you personally, but a result of the needs and requirements of the study. We appreciate the time you gave.

If yes

Go to question X.

The survey will take about 30 minutes of your time. Because this is a research study we need to get your written permission to begin the survey. I will read this consent permission form to you and will answer any questions you have. If you agree to participate in our survey, we ask that you sign the consent form before we begin.

Are you still interested in participating in the survey?

If no,

We appreciate you speaking with us. If you should change your mind and decide to participate in the survey, feel free to contact our study office at

XXX-XXXX[GIVE STUDY FLIER]

If yes,

Thanks again for your willingness to participate and your interest in our study! I will now review the study details in the consent/permission form. [READ CONSENT FORM, GET SIGNATURE, & GIVE PARTICANT A COPY]

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