Form Approved
OMB No. 0920-0572
Expiration Date 03/31/2018
Submission under
0920-0572 Health Message Testing System
Attachment 13: Consumer Web-based Survey Screener
Public reporting burden of this collection of information is estimated to average 2 hours 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 (0920-0572)
High Impact Prevention Message Testing
Consumer Web-based Survey Screener
We are asking people to be in a research study that will help us learn more about what people think about HIV related topics and messages. RTI, a research company in North Carolina, is conducting the study. The Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia is funding the research.
To see if you are a good match for this study, we will need to ask you some personal questions. Some of the questions will be about your sexual orientation and your HIV status, if you know it. It is your choice to answer the questions. Your answers will be kept private to the extent allowed by law. You can refuse to answer any question or stop at any time.
May we ask you the questions to see if this you are a good match for this study?
Yes [CONTINUE]
No [TERMINATE]
In what language would you like to answer the questions?
English
Spanish
1. How old are you?
Age__________ [INELIGIBLE IF UNDER 18 OR OVER 64]
8 Don’t know [INELIGIBLE]
9 Prefer not to answer [INELIGIBLE]
2. What was your sex at birth?
1 Male
2 Female
8 Don’t know [INELIGIBLE]
9 Prefer not to answer [INELIGIBLE]
3. Do you consider yourself to be male, female, or transgender? (check only one)
1 Male
2 Female
3 Transgender Man (or Transmale or Transman)
4 Transgender Woman (or Transfemale or Transwoman)
8 Don’t know [INELIGIBLE]
9 Prefer not to answer [INELIGIBLE]
4. Are you of Hispanic or Latino origin?
1 Yes
2 No
9 Prefer not to answer [INELIGIBLE]
5. Please indicate your race. Are you? You may select one or more races.
1 White
2 Black or African American
3 Asian
4 Native Hawaiian or Other Pacific Islander
5 American Indian or Alaska Native
6 Other race [Specify: ]
8 Don’t know [INELIGIBLE]
9 Prefer not to answer [INELIGIBLE]
6. In what country or territory were you born?
1 United States
2 Puerto Rico
3 Mexico
4 Cuba
5 Other [Specify: ]
9 Prefer not to answer
7. How many years have you been living in the United States?
[If less than one year, put 0 in the space. Round to whole years]
_____________years
8. What language are you most comfortable using with your family and friends?
1 English
2 Spanish
3 English and Spanish equally
4 Other [Specify: ]
9 Prefer not to answer
9. What is the highest grade or year of school you finished?
1 Never attended school or only attended kindergarten
2 Grades 1 through 8 (elementary)
3 Grades 9 through 11 (some high school)
4 Grade 12 or GED (high school graduate)
5 College 1 year to 3 years (some college or technical school)
6 College 4 years or more (college graduate)
9 Prefer not to answer
10. Which best describes your total personal income during the past year?
1 Less than $20,000
2 $20,001 to $30,000
3 $30,001 to $40,000
4 $40,001 to $50,000
5 $50,001 or more
9 Prefer not to answer
11. Which do you consider yourself to be?
1 Gay or homosexual
2 Bisexual
3 Straight or heterosexual [INELIGIBLE]
4 Other [Specify: ] [INELIGIBLE]
9 Prefer not to answer [INELIGIBLE]
12. What is your current relationship status?
1 Single
2 Married to a man
3 Married to a woman
4 In a relationship with a man
5 In a relationship with a woman
9 Prefer not to answer
13. Do you currently have health insurance or health care coverage?
1 Yes
2 No
3 Don’t know
9 Prefer not to answer
14. In what ZIP Code do you currently live? ______________
15. What is your job title or role?
1 [Public Health Professional: e.g. epidemiologist, health communicator, health educator, etc] Single
2 [Healthcare Provider: e.g. doctor (MD, DO), nurse, nurse practitioner, physician’s assistant] Married to a man
3 [General Consumer: neither a Public Health Professional nor a Healthcare Provider]
4 [Other:___________]
16. Have you ever been tested for HIV? An HIV test checks whether someone has the virus that causes AIDS.
1 Yes
2 No [SKIP TO X]
9 Prefer not to answer [INELIGIBLE]
17. The next question is about the result of your HIV test. What was the result of your most recent HIV test?
1 I tested positive for HIV. [Go to X]
2 I tested negative for HIV. [Go to X]
3 My results were unclear. [Go to X]
8 I never got my results/Don’t know [Go to X]
9 Prefer not to answer [INELIGIBLE]
17a. [IF POSITIVE] When did you first test positive?
DATE (MM/YYYY):__________ [ERROR CHECK: CANNOT BE BEFORE 1985 OR BEYOND CURRENT DATE]
9 Prefer not to answer
If positive, skip questions 18 through 20, and proceed to question 21.
18. When did you have your first HIV test?
DATE (MM/YYYY):__________ [ERROR CHECK: CANNOT BE BEFORE 1985 OR BEYOND CURRENT DATE]
19. In the past 2 years, that is, since [insert calculated month and year], how many times have you been tested for HIV? _______
20. When did you have your most recent HIV test?
DATE (MM/YYYY):__________
20. The next question is about the result of your HIV test. What was the result of your most recent HIV test?
1 I tested positive for HIV. [Go to X]
2 I tested negative for HIV. [Go to X]
3 My results were unclear. [Go to X]
8 I never got my results/Don’t know [Go to X]
9 Prefer not to answer [INELIGIBLE]
20a. [IF POSITIVE] When did you first test positive?
DATE (MM/YYYY):__________ [ERROR CHECK: CANNOT BE BEFORE 1985 OR BEYOND CURRENT DATE]
9 Prefer not to answer
21. Have you had oral sex (mouth on the penis or vagina), vaginal sex (penis in the vagina), or anal sex (penis in the butt) with a woman in the past [INSERT TIME FRAME]?
1 Yes
2 No
9 Prefer not to answer [INELIGIBLE]
22. Have you had oral sex (mouth on the penis) or anal sex (penis in the butt) with a man in the past [INSERT TIME FRAME]?
1 Yes
2 No [INELIGIBLE]
9 Prefer not to answer [INELIGIBLE]
If eligible:
Thank you for answering these questions. You are eligible to take part in the survey. Please click the button below to go to the survey consent form.
If ineligible:
Thank you for answering all of the questions. You are not eligible to be in this study because you did not meet our eligibility criteria. There are many possible reasons why people are not eligible for the study. These reasons were decided earlier by the researchers. We value your interest in this research study. Thank you for being willing to help us.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Allie Lieberman |
| File Modified | 0000-00-00 |
| File Created | 2021-01-25 |