Att 9 Changes made to the eligibility screener

OMB No. 0920-0794

Changes to the THBS Eligibility Screener

Form Approved:

OMB No: 0920-0794

Expiration Date: 12/31/2010XX/XX/XXXX

Transgender HIV Behavioral Survey (PILOT):: Eligibility Screener

____________________________________________________

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 Information Collections Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0794).

AUTO1 Survey Version: THBS-Pilot Version MM/DD/YYYY

AUTO2 Date of Interview: __ __/ __ __ / __ __ __ __ AUTO3 Time Begin __ __:__ __  AM  PM

^{(M M / D D / Y Y Y Y )}

AUTO3 Time eligibility screener began: __ __:__ __ : __ __ [Military time HH:MM:SS]

INT1. Interviewer ID __ __

INT2. City __ __

INT3. Survey ID ___ ___ ___ ___

INT4. Field Site ID ___ ___ ___ ___

INT5. Interviewer: Is the participant a seed?

No………………….……………….………….. 0 Yes….……………………………….……......... 1

SAY: I’d like to thank you again for your interest in this health survey. Remember that all information you give me will be kept private and I will not ask for your name. First, 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 survey.

IF RESPONDENT IS A SEED (INT5=1) skip to E2;

ES1. Which of the following describes how you know the person who gave you this coupon? You can choose more than one answer.

[GIVE RESPONDENT FLASHCARD A. READ CHOICES, Check all that apply.]

A friend ……................................................................... 1

A sex partner, girlfriend/boyfriend, husband/wife...... 2

A relative or family member…………………............... 3

A co-worker……………………………………………. 4

A person you use drugs with…………………............... 5

A person you buy drugs from………………….............. 6

A person you share needles with…………………......... 7

An acquaintance (that is, a person you know,

but do not consider friend) ………… 8

You don’t know the person/just met them (a stranger)… 9

Refused to answer……………………………………… .R

Age Assessment

ES2. What is your date of birth?

__ __ / __ __ / __ __ __ __

[Refused = .R, Don't know = .D] ^{(M M / D D / Y Y Y Y )}

If ES2 is (.R, .D) skip to the Eligibility section;

AUTO4 AGE: ES2 - AUTO2/365.25

If AGE < 15 skip to the Eligibility section;

ES3. So, you are [AGE] years old. Is that correct?

No………………….……………….………….. 0

Yes….……………………………….……......... 1

IF ES3 = 0 go back to the Age Assessment section;

Previous Participant Assessment

ES4. During 2008, did you already complete any part of the health survey that [Insert Project Name] is conducting? It could have been here or at another location.

No………………….……………….………….. 0

Yes….……………………………….……......... 1

Refused to answer………………………..…….. .R

Don't know.……………..……………….......... .D

Ethnic Assessment

ES5. Do you consider yourself to be Hispanic or Latino?

No………………….…………………………… 0 Yes……………………………………………… 1

Refused to answer……………………………… .R

Don't know……………..……………………... .D

If ES5 in (0, .R, .D) skip to ES7;

ES6. What best describes your Hispanic or Latino ancestry?

[Read choices, Check all that apply.]

Mexican…………….…..……………………… 1

Puerto Rican………..…………………………... 2

Cuban…………...…………………..………….. 3

Dominican……...…………………..………….. 4

Some other Hispanic or Latino ancestry……... 5

(Specify other ancestry: _______________________)

Refused to answer………....…………………… .R

Don't know………………………..……………. .D

Racial Assessment

ES7. Which racial group or groups do you consider yourself to be in? You may choose more than one option.

[GIVE RESPONDENT FLASHCARD B. READ CHOICES, Check all that apply.]

American Indian or Alaska Native…………… 1

Asian ..……………………..………………....... 2

Black or African American ……………..…….. 3

Native Hawaiian or Other Pacific Islander……... 4

White ……………..……………………………. 5

Refused to answer……………………………… .R

Don't know………………………..……………. .D

Residency Assessment

ES8. What county do you currently live in? _______________________________________

(Responses in computer program will include all eligible counties from participating MSA)

Other…………………………………………. 88

(Specify other county: _____________________)

If ES8 = 88 (or other county) skip to the Gender Assessment Section;

ES9. How long have you been living in [say project area]?

Months __ __[Interviewer: If response is in months, enter 0 below and then enter the number of months in the next screen.]

Years __ __

: __ __ [Refused = .R, Don't know =.D]

Months: __ __

Gender Assessment

ES10. What was your physical sex assigned at birth?

[Check only one]

Male…...……………………………………….. 1

Female…....…....……………………………….. 2

Intersex…………..………....………………….. 3

Refused to answer………....…………………… .R

Don't know……………..……………………... .D

ES11. Do you consider yourself to be male, female, or transgender?

[Check only one]

Male…………………………………………….. 1

Female …………………………………………. 2

Transgender ……………………………………. 3

Other …………………………………………… 4

(Specify other gender: ______________________)

Refused to answer……………………………… .R

Don't know……………..……………………... .D

If ES7 is (2, 3, .R, .D) then skip to Auto5

If ES7 is (1) and ES8 is (2, 3) then skip to ES10

ES12. In the past 12 months, have you ever lived as a woman? By living as a woman, I mean dressing and presenting yourself as a woman.

No ………….……………………… 0

Yes …………………… 1

Refused to answer……………………………… .R

Don’t know……………………………… .D

Network Size Assessment

SAY: I would like to ask you about some people you know personally. By “know personally”, I mean they know you and you know them.

ES10. About how many people do you know personally who were born male but identify, live, act, or consider themselves to be a woman and who are 15 years of age, live in [project area], and who you’ve seen in the past 30 days?

INTERVIEWER: USE FLASHCARD A

[Refused= .R, Don’t Know= .D] ___ ___ ___

If ES10 is (0, .R, or .D) and ES8 is (1) and ES9 is (0, .R, .D) then skip to INT6

If ES10 is (0, .R, or .D) and ES8 is (1) and ES9 is (1) then skip to INT7

If ES10 is (0, .R, or .D) and ES8 is (2, 3) then skip to INT7

ES10a. Of these [insert number from ES10] persons that you have seen in the past 30 days how many are Latino or Hispanic?

[Refused= .R, Don’t Know= .D] ___ ___ ___

SAY: What is the race of these [insert number from ES10] persons that you have seen in the past 30 days? That is how many are:

ES10b. African American or Black;: [Refused= .R, Don’t Know= .D] ___ ___ ___

ES10c. American Indian or Alaska Native: [Refused= .R, Don’t Know=.D] ___ ___ ___

ES10d. Asian: [Refused= .R, Don’t Know= .D] ___ ___ ___

ES10e. Native Hawaiian or Other Pacific Islander: [Refused= .R, Don’t Know= .D] ___ ___ ___

ES10f. White: [Refused= .R, Don’t Know= .D] ___ ___ ___

If ES8 is (1) and ES9 is (1) then skip to INT7

If ES8 is (2, 3) then skip to INT7

Interviewer Assessment

INT6 Interviewer: Does this person meet the protocol definition of transgender?

No……………………………………………. 0

Yes, identifies or has a feminine presentation…. 1

Yes, other reason……………………. 2

(Specify___________________________________)

Ability to Participate Assessment

INT7. Interviewer: Is this person alert and able to complete the health survey in English or Spanish?

No……………………………………………. 0

Yes……………………………………………. 1

If INT7 =1 skip to the Eligibility section;

INT7a. Interviewer: Why is this person unable to participate in the health survey?

Language Barrier …………………………. 1

(Specify language barrier: ____________________)

Not alert …………………………. 2

Other…………………………………………. 3

(Specify other reason:_________________________)

Eligibility

AUTO5 ELIGIBLE = (calculated using the following eligibility logic)

Eligibility Logic:

Age: AGE >= 15 years

Not a previous participant: ES4 = No or 0

Residence: ES8 ne 88, Refused or Don’t know

Gender: ES10 = Male and (ES11 = Female or Transgender

or ES11=Male AND ES12=Yes)

Can take English or Spanish survey: INT7=Yes

AUTO6 Time Eligibility Screener Ended __ __:__ __  AM  PM: __ __:__ __ : __ __ [Military time HH:MM:SS]

Not Eligible

If Participant NOT ELIGIBLE for THBS

SAY: Thank you for answering these questions. Unfortunately, the computer has not selected you to participate in the health survey. Thank you again for your time.

Interviewer: End Interview.

Eligible

If Participant IS ELIGIBLE for THBS

SAY: Congratulations! The computer has selected you to participate in the health survey. Let me tell you about it.

In the survey, the term “transgender” is used broadly to refer to persons who identify, live, or present as a gender other than the one associated with their physical sex at birth. The purpose of the survey is to learn more about risks for HIV among transgender persons. Let me tell you more about it.

Consent

Interviewer: Conduct the local IRB-approved consent process

CONSENTA. Do you agree to take part in the survey?

No………………….……………….………..... 0

Yes….……………………………….……........ 1

If CONSENTA = 0: Thank the respondent for doing the eligibility screener;

CONSENTB. Do you agree to HIV counseling and testing?

No………………….……………….………..... 0

Yes....……………………………….……......... 1

If CONSENTB=0: This pop-up box should appear Interviewer: You have documented that the person DID NOT consent to HIV counseling and testing. If this is not correct, please arrow back and re-enter the consent for HIV testing.

If CONSENTB = 0 skip to the Core Questionnaire;

CONSENTC. Do you agree to having other lab tests (if offered)?

No………………….……………….……….....0

Yes….……………………………….……........ 1

Does not apply…………………..….……......... 8

CONSENTD. Do you agree to storing a blood sample for future testing?

No………………….……………….……….... 0

Yes….……………………………….……....... 1

Does not apply…………………..….……........ 8

Page 11