Screener - HIV+

Form Approved

OMB No. 0920-0572

Exp. Date XX/XX/XXXX

Formative Research on the Act Against Aids Campaign - Message, Concept and Materials Testing

Screening Instrument

Act Against AIDS— HIV Positive Audiences

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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0572).

Screening Instrument

Act Against AIDS— HIV Positive Audiences

OUTBOUND CALLS/RETURNING MESSAGES READ: Hello, may I speak with ____________?

(once confirmed that the correct individual is on the phone, proceed with “Inbound calls” script below.

If individual is not available or an answering machine is reached read, “Hello, this is ___________ from RTI International returning [name’s] phone call about a research study he/she is interested in participating in. I can be reached at XXX-XXX-XXXX. Thank you!”

INBOUND CALLS READ: “Hello, my name is __________ and I’m from RTI International. We are inviting people to take part in an interview which is part of a research study.

We will meet one time for one hour to talk about materials under development such as a public service announcement, or PSA, billboard, brochure or other advertisement about HIV. We are interested in your opinions about the materials and how well you think they work.

RTI International, a nonprofit company in North Carolina, is conducting these interviews. The Centers for Disease Control and Prevention--or CDC-- is sponsoring the interviews.

We are recruiting HIV-positive people with differing backgrounds and characteristics. Some of the questions I would like to ask you now will help us see if you are eligible to take part in an interview. Others will help us describe all of the people we have talked to. It is your choice to answer the questions. Your answers will be kept private to the extent allowable by law. You can choose not to answer a question or stop at any time. The questions will take a few minutes to complete.

If you are eligible and are interested, we will schedule you for an interview. Everything you tell me in the interview will be private to the extent allowable by law. We will never link your name with any of your comments. If you take part in an interview, we will give you $40 as a token of appreciation.

May I ask you the questions now?”

Yes..................1 [Continue]

No....................2 [End]

Procedures for Recording and Limiting Information

Only record information for the questions in the screener. If any informant reveals additional personal information, thank them for being helpful, but guide them back to the screener questions- “That is interesting to learn, but can I now ask you about. . .”

1. What is your gender? (Circle one)

• Male

• Female

2. In which of the following categories does your age fall: (Circle one)

• Under 18 years of age INELIGIBLE: Read script for ineligibles

• 18–24 years of age

• 25–34 years of age

• 35–44 years of age

• 45–54 years of age

• 55–64 years of age

• 65–74 years of age

• 75 years of age or older

3. What is the highest level of education you have completed? (Circle one)

• Grade school

• Less than high school graduate/some high school

• High school graduate or completed GED

• Some college or technical school

• Received four-year college degree

• Some post graduate studies

• Received advanced degree

• Other: ____________

4.. Please indicate your race or ethnic background. Are you?

Ethnicity:

• Hispanic or Latino

• Not Hispanic or Latino

Race: SELECT ONE OR MORE.

• White/Caucasian

• Black or African-American

• American Indian or Alaska Native

• Native Hawaiian or Other Pacific Islander

• Asian

5. Which of the following categories best describes your total, annual household income? (Circle one)

• Under $20,000/year

• $20,001–$30,000/year

• $30,001–$40,000/year

• $40,001–$50,000/year

• $50,001–$60,000/year

• $60,001–$80,000/year

• $80,001–$100,000/year

• Over $100,000/year

6. What is your current relationship status? Are you…? (Circle one)

• Single

• Married to a man

• Married to a woman

• In a relationship with a man

• In a relationship with a woman

• Divorced or Widowed

• Refused

7. Have you ever had an HIV test? (Circle one)

• Yes

• No INELIGIBLE: Read script for ineligibles

8. What was the result of your last HIV test? (Circle one)

• Positive

• Negative INELIGIBLE: Read script for ineligibles

• Don’t know INELIGIBLE: Read script for ineligibles

9. Now I am going to ask you to describe your sexual identity. Would you describe yourself as: (Circle one)

• Homosexual or “gay” or same gender loving

• Bisexual or two spirited

• Other, specify ____________________________________

• Heterosexual or “straight”

• Don’t know

• Decline to answer

10. Some people notice information about health on the Internet, even when they are not trying to find out about a health concern they have or someone in the family may have. Have you read such health information on the Internet in the past 12 months? (Circle one)

• No

• Yes

11. About how often do you use the Internet? (Circle one)

• Several times a day

• About once a day

• 3–5 days a week

• 1–2 days a week

• Every few weeks

• Less often

• Never

• Don’t know/refused

IF INDIVIDUAL IS 18 YEARS OR OLDER AND HIV-POSITIVE,

READ INVITATION FOR ELIGIBLE PARTICIPANTS