Eligibility screener

Attachment 5A. Eligibility Screener

Behavioral Assessment Component of the Behavioral Assessment and Rapid Testing (BART) Project

October 14, 2010

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

Division of HIV/AIDS Prevention

Behavioral and Clinical Surveillance Branch

Centers for Disease Control and Prevention

1600 Clifton Road NE, Mailstop E-46

Atlanta, GA 30333.

Peter Thomas, PhD, MPH

Project Officer
Email: PThomas2@cdc.gov

Voice: (404) 639-6266

Fax: (404) 639-8640

Form Approved

OMB No. 0920-XXXX

Expiration date XX.XX.20XX

APPENDIX 5A: BART INTERVIEW ELIGIBILITY SCREENER

Public reporting burden of this collection of information is estimated to average 2 minutes per response. 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/ASDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-XXX)

APPENDIX 5A: BART INTERVIEW ELIGIBILITY SCREENER B-1. Device ID #:__ __ __ __ B-2. Subject ID#:__ __ __ __ B-3. Event Type: __ Gay Pride (Group 1) __ Minority Gay Pride (Group 2) __ Black Spring Break (Group 3) __ Social or Cultural Events Attracting African Americans (Group 4) B-4. Date of interview: __ __/ __ __ / __ __ __ __ (M M / D D / Y Y Y Y ) B-6. Event location: County ________________________ OR City _______________________
SAY: Hi, my name is [name] and I’m with the [local agency name]. We are conducting a short anonymous health interview and I would like to ask you a few questions to see if you qualify. [If incentives are provided add “If you are eligible and complete the interview, you will receive a small gift for your time.”] Are you interested?
Int1	[Interviewer: Did respondent accept intercept?]
		No………………………………………………............................ 0			 end interview
		Yes……………………………………………….......................... 1
Int2	[Interviewer: How was respondent encountered?]
		Interviewer approached respondent, systematic selection...………... 1
		Interviewer approached respondent, not systematic selection.……... 2
		Respondent approached interviewer…………..……………………. 3
		Respondent requested HIV test and then agreed to interview……… 4
Int3	[Interviewer: Was respondent alone, with one other person, or with more than one other person when approached?]
		Alone……………………………………………………....………... 1
		With one other person……………………………………….…….... 2
		With more than one person…………..……………………………... 3
SAY: Thanks. All information you give me will be kept confidential and I will not ask for your name so it is anonymous. I will ask you a few questions about yourself and then the computer will determine if you have been selected to participate in the health interview.
Int4	What is your age? _ _ _
	[Refuse to answer = 777, Don’t know = 999]
If B-3 = 1, 2, or 4 and age < 15 continue interview through Int9, then skip to SAY-0 box. If B-3 = 3 and age < 15 or > 35 continue interview through Int9, then skip to SAY-0 box.
Int5	Do you consider yourself to be Hispanic or Latino/a?
		No ………………...……………..…..…………………………...…. 0
		Yes………...………………...….….……………………..……..….. 1
		Refuse to answer……..………..…...…..................................….…... 7
		Don’t know…………........……………………………………..…... 9
Int6	Which of the following racial groups do you consider yourself to be in? You can choose more than one group. [Read all choices. Choose all that apply]
		American Indian or Alaskan Native...………………………...……. 1				 skip to Int8
		Asian ……………………………….……..………………………... 2				 skip to Int8
		Black or African American ……………………………….……..…. 3				 skip to Int8
		Native Hawaiian or other Pacific Islander………………………….. 4				 skip to Int8
		White...................…..…..…………………………............................ 5				 skip to Int8
		Some other race…............................................................................... 6
		Refuse to answer…..…..…………………………………...……….. 7				 skip to Int8
		Don’t know……..………………..………………………………………. 9				 skip to Int8
If B-3 = 3 or 4 and Int6 ≠ 3 continue interview through Int9, then skip to SAY-0 box. If B-3 = 2 and Int6 does not include 1, 2, 3, 4, or 6  continue interview through Int9, then skip to SAY-0 box.
Int7	If “other” race, specify: ____________________________________________
Int8	What was your sex at birth?
		Male...………………………...…………………………………….. 1
		Female…………………………….……..………………………...... 2
		Intersex or ambiguous ……………………………….……..……… 3
		Refuse to answer…..…..…………………………………...……….. 7
		Don’t know……..………………..………………………………………. 9
If Int8 > 2 continue interview through Int9, then skip to SAY-0 box. If B-3 = 1 or 2 and Int8 ≠ 1 continue interview through Int9, then skip to SAY-0 box.
Int9	Now some people don’t identify as their birth sex. Tell me, do you still consider yourself to be [response to Int8]?
		Male...………………………...…………………………………….. 1
		Female…………………………….……..………………………...... 2
		Intersex or transgender ……………………………….……..……… 3
		Refuse to answer…..…..…………………………………...……….. 7
		Don’t know……..………………..………………………………………. 9
If Int9 ≠ Int8 or Int9 > 2 skip to SAY-0 box.
Int10	[Interviewer: Is the respondent able to participate?]
		No ………………...……………..…..…………………………...…. 0				 Int11
		Yes………...………………...….….……………………..……..….. 1				 skip to SAY-C box
Int11	[Interviewer: Why is the respondent not able to participate?]
		Does not speak English……………………...……………………… 1
		Intoxicated……………………….……..………………………........ 2
		Apparent mental disability………………………….……..………... 3
		Does not meet eligibility criteria…………………………...……….. 4
		Other……..………………..………………………………………………. 5
SAY-0: Thank you for answering these questions. Unfortunately the computer has not selected you to participate in the health interview. Thank you again for your time. Have a nice day.
SAY-C: You are eligible to participate in an important health research project conducted by the [agency name(s)] and the Centers for Disease Control and Prevention (CDC).  The purpose of this project is to improve HIV prevention in your community.  If you agree to take part in this project, a trained interviewer will ask you questions about your health, sexual behavior, drug use, beliefs, attitudes, practices, and health services you have received.  This interview will take no more than 15 minutes. You will receive a [gift / gift card] if you answer the questions, to thank you for taking part in the survey.   The risk from taking part in this project is minimal. The interview is completely anonymous; we will not collect your name or other identifying information and all of the information you give us will be kept private.  Taking part in this project is your decision.  Some questions are personal and may make you uncomfortable.  You may refuse to answer these and there will be no penalty to you.  You may also end the interview at any time if you wish. The benefit of taking part in this project is that it helps us help people who may have trouble getting health services, like HIV testing, that help prevent HIV infection and we can tell you about places to go for free HIV testing as well. The information we collect from you may be released in published reports. To protect your privacy, we will group your answers together with answers from others. We will send information from this project to the CDC, but will not send CDC any information that could identify you. If you have questions about the interview or your rights as a participant, I can provide you with the names and phone numbers of responsible persons at [agency name(s)] and at the CDC.  Do you have any questions?
Int12	[Interviewer: Does respondent agree to participate in the interview?]
		No ……………...……………..…..…………………………...…. 0			 end interview
		Yes………...………………...….….……………………..……….. 1			 begin interview

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