Eligibility Screener

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

“Community-based Organization Outcome Monitoring Projects for CBO HIV Prevention Services Clients”

Attachment 3a# Participant Interview Eligibility Screener Category 1

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-New)

Category 1 Eligibility Screener- Participant Interview

AUTO1. Date screener was administered: __ __/ __ __ / __ __ __ __ (MM/DD/YYYY)

INT1. PCOC Staff ID __ __ __

INT2. Other Staff ID __ __ __

INT3. CBO Name ______________________

INT4. Participant Screener ID __ __ __

CONF1. Confirm that this participant is HIV-positive.

• Yes, this participant is HIV-positive

• No, this participant is not HIV-positive

CONF2. Confirm that this participant has had > 1 CBO-HPS referral to HIV medical care in the past 30 days (since MM/DD/YYYY).

• Yes, this participant has had > 1 CBO-HPS services in past 3 months

• No, this participant has not received any CBO-HPS services in past 3 months

CONF3. What was the date of the CBO-HPS referral to HIV medical care?

__ __/ __ __ / __ __ __ __ (MM/DD/YYYY).

Baseline must take place 30 days after CBO-HPS referral to HIV medical care.

Only participants who meet the three criteria above can participate in this project.

___________________________________________________ __

Staff: I’d like to thank you again for your interest in [PROJECT NAME]. Remember that all information that you share will be kept private. First, I will ask you a few questions to determine if you are eligible to participate.

ES1. How old are you today? ___ ___

[Refused = 777, Don't know = 999]

ES2. [THIS CBO NAME] and [OTHER CBO NAME] are both conducting these interviews with HIV-positive people in coming months. The one that I am interviewing you for is called [PROJECT NAME]. The other one is called [OTHER PROJECT NAME]. During [TIMEFRAME], did you already complete at least part of an interview with staff from that agency? The interview would have been about XXX.

• Yes

• No

• Declined to answer

• Don’t know

If participant is < 13 years old, or they indicated they had already completed at least part of an interview with another CBO, skip to END1.

End 1. If the participant IS NOT ELIGIBLE:

Interviewer: Thank you for answering these questions. Unfortunately, you don’t meet the criteria to participate in these interviews. But thank you again for your time and we will be in touch about future studies if you are interested.

End Interview.

End 2. If the participant IS ELIGIBLE:

Staff: Congratulations! You are eligible to participate in the interview. Let me tell you about it. [Proceed with the local IRB-approved consent process.]

C1. Did the participant provide written consent to be interviewed and take part in the project?

• Yes

• No

C2. We are interested in knowing why people do not want to participate in the interviews. Would you mind telling me which of the following best describes the reason you do not want to participate? [Read choices. Check all that apply.]

• You don’t have time

• You don’t want to talk about these topics

• You’d rather not say why

• Some other reason

Staff: Thank you again for your time, we appreciate you considering our project. Please let us know down the road if you change your mind.

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