Web-based Screener and Questionnaire (Screenshots)

Blood Study MSM Survey Draft January 3, 2012

There was an error on your page. Please correct any required fields and submit again. Go to the first error
Welcome
Researchers at the Blood Systems Research Institute and University of California San Francisco's Center for AIDS Prevention Studies are conducting
a study about blood donation. This study explores men's views about blood donation policies that are designed to screen out donors with a history
of male-male sexual contact.
The Principle Investigators for this study are Dr. Brian Custer, PhD, MPH and Dr. Nicolas Sheon, PhD.
For more information about the study, you may contact the study team.
email: blood@ucsf.edu
phone: (415) 597-9109

Please be sure to read the privacy statement, eligibility requirements, and survey instructions
below before you continue. Failure to do so may result in your inability to successfully complete the survey.
If you are eligible and complete the survey, we will email you a $10 Amazon.com Gift Code within 30 days. The survey takes approximately 20
minutes to complete.

PRIVACY

If you click the "Next Page" button at the bottom of this page to proceed with participation in the survey, specific electronic information will
be automatically collected from your web browser and Internet connection. None of this information will be used to personally identify you. If you do
not continue to the next page of the survey, none of this information will be collected from you. This allows you to decide if you want to share
the information with the study researchers. The information includes:
file:///C|/Documents%20and%20Settings/300519/Desktop/More%20Web%20Survey/s1.htm (1 of 2) [5/18/2012 6:57:53 AM]

Blood Study MSM Survey Draft January 3, 2012

●

●

●

IP (internet Protocol) address: Your computer uses an IP address every time you connect to the Internet. It is a unique number that is used
to identify computers on a network, so that data requested (such as web pages) can be sent to the computer.
General information about the web browser, type of device (Dell computer, iPad, etc.) and operating system you are using. This information is
sent automatically by most web browsers when you visit any web site.
The "referrer,", which is information passed along by your web browser that references the web site you linked from to reach this survey.

ELIGIBILITY

The survey will begin by asking a number of questions to determine if you qualify to participate in the study.
You may complete only one survey. In addition, only a single member of a household is eligible to take the survey. Additional criteria are explained
later in the survey's consent document.
If you are accessing this survey using an "anonymous web proxy" that masks or alters your true IP address, or any other method that alters
information about your Internet connection, you are ineligible to participate in this study.

INSTRUCTIONS FOR COMPLETING THE SURVEY

If you want to return to a previous page of the survey, click the "Previous Page" button located at the bottom of the survey web page. Do not
use the "Back" button in the toolbar of your web browser.
You may exit the survey at any time and then return later to complete the survey, but only by clicking on the box titled "Click
here to save your progress and continue the survey later," which appears at the bottom of every survey page. When you return to
the survey web site, the questions will begin exactly where you left off. We ask that you please complete the survey within three days of beginning it.

Next Page
0%

file:///C|/Documents%20and%20Settings/300519/Desktop/More%20Web%20Survey/s1.htm (2 of 2) [5/18/2012 6:57:53 AM]