Form Approved
OMB No. 0920-XXXX
Expiration Date: XX/XX/XXXX
Evaluation of Free Rapid HIV self-testing in MSM (eSTAMP): Field Performance Study
Attachment 3a
Eligibility Screener
Public reporting burden of this collection of information is estimated to average 3 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)
Part 4 Eligibility Screener
____________________________________________________
AUTO1. Date of Eligibility Screener: __ __ / __ __ / __ __ __ __
(M M / D D / Y Y Y Y)
AUTO2. Time Began Eligibility Screener __ __:__ __:__ __ [24 Hour time HH:MM:SS]
Thank you for your interest in our study. Emory University and MANILA Consulting Group, Inc. are conducting the study, which is funded by the Centers for Disease Control and Prevention (CDC). First, we have a few questions to determine if you’re eligible. Questions marked with a red asterisk (*) are required questions that you must answer to move forward.
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ES1. How old are you?* __ __
If ES1 <18 skip to End1
ES2a. What U.S. State or U.S. Territory do you live in?
[DROP DOWN MENU LISTS STATES AND TERRITORIES and “I do not live in the United States” for non-U.S. States or Territories]
ES2b. What zip code do you live in?
__ __ __ __ __
If ES2 ≠ one of the study cities, continue questions but End= End 1
ES3. Do you consider yourself Hispanic or Latino?
No
Yes
I prefer not to answer
ES4. Which racial group or groups do you consider yourself to be in? Check all that apply.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
ES5. What was your sex at birth?
[Check only one]
Male
Female
Intersex/Ambiguous
I prefer not to answer
ES6. Do you consider yourself to be male, female, or transgender?
[Check only one]
Male
Female
Transgender
I prefer not to answer
If ES5 or ES6 ≠ “Male”, continue questions but End=End 1
The next question is about having sex with other men. For this question, "anal sex" means you put your penis in his anus (butt), or he put his penis in your anus (butt).
ES7. Have you had anal sex with a man in the past 12 months?
No
Yes
I prefer not to answer
If ES7 ≠ “Yes”, continue questions but End=End1
ES8. Have you ever been diagnosed with a bleeding disorder?
No
Yes
I don't know
I prefer not to answer
If ES8 = “Yes”, “I don’t know” or “I prefer not to answer”, continue questions but End=End1
The next questions are about your HIV status. Please remember that your answers are anonymous and will be kept private.
ES9. Have you ever been tested for HIV? An HIV test checks whether someone has the virus that causes AIDS.
No
Yes
I prefer not to answer
If ES9 = “No”, go to End 2
If ES9 = “Yes” go to Q10
If ES9 = “I prefer not to answer”, go to End 1
ES10. What was the result of your most recent HIV test?
Negative
Positive
Never obtained results
Indeterminate I prefer not to answer
If ES10 = “I prefer not to answer”, go to End 1
If ES10 = “Negative” or “Never obtained results” or “Indeterminate”, go to ES11
If ES10 = “Positive”, then classify to HIV+ group, go to End 2 and proceed to registration process
ES11. Are you taking antiretroviral medications to prevent HIV?
No
Yes
I don't know
I prefer not to answer
If ES11 = “Yes”, “I don’t know” or “I prefer not to answer”, skip to End 1
If ES11 = “No” then go to ES12
ES12. Have you ever been part of an HIV vaccine trial?
No
Yes
I don't know
I prefer not to answer
If ES12 = “Yes”, “I don’t know” or “I prefer not to answer”, skip to End 1
If ES12 = “No” then classify to RCT (HIV negative/unknown), go to End 2 and proceed to registration process
____________________________________________________
End 1. If the participant is not eligible:
Thank you for your interest in this health study. Unfortunately, the system did not select you to participate any further.
If you want to learn more about HIV, where to get more information, or where to get tested in your area, please click on the following link: http://www.aidsvu.org/
To get more information about HIV, please visit: www.cdc.gov/hiv
Otherwise, you can close your browser window. Thank you for your time.
End survey.
End 2. If the participant is eligible:
Congratulations! You are eligible to participate in this health study.
Please click on the following link to complete the registration process and enroll into this study: [link to registration]. Thank you for your time.
Continue to registration.
AUTO3. Time Ended Eligibility Screener: __ __:__ __: __ __ [24 Hour time HH:MM:SS]
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Freeman, Arin (CDC/OID/NCHHSTP) |
File Modified | 0000-00-00 |
File Created | 2021-01-27 |