Form Approved
OMB No. 0920-0920
Exp. Date XX-XX-XXXX
Data Collection Through Web Based Surveys for Evaluating Act Against AIDS Social Marketing Campaign Phases Targeting Consumers
Sample Study Screener
CDC estimates the average public reporting burden for this collection of information as 2 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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, SD-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0920).
[INSERT PHASE NAME]
Study Screener
Thanks for your willingness to complete this online survey. We are asking [INSERT TARGET GROUP] to take part in a research study about [INSERT TOPIC].
The purpose of the research is to [INSERT PURPOSE].
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. 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 you are a good match for this study?
1 Yes [CONTINUE]
2 No [INELIGIBLE]
S1. How old are you?
Age__________
8 Don’t know
9 Prefer not to answer
S2. What is your current gender identity? (Select ALL that apply)
1 Male
2 Female
3 Transgender Male/Transman/FTM
4 Transgender Female/Transwoman/MTF
5 Genderqueer
6 Another category [Specify: ]
9 Prefer not to answer
S3. What sex were you assigned at birth? (Select one)
1 Male
2 Female
3 Prefer not to answer
S4. Do you consider yourself to be male, female, or transgender? (check only one)
1 Male
2 Female
3 Transgender
8 Don’t know
9 Prefer not to answer
S5. Are you of Hispanic or Latino origin?
1 Yes
2 No
9 Prefer not to answer
S6. 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
9 Prefer not to answer
S7. 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 Some high school
4 High school graduate (includes GED)
5 Some college or technical school
6 College or technical school graduate
8 Don’t know
9 Prefer not to answer
S8. Which best describes your total personal income during the past year?
1 Less than $21,000
2 $21,000 to $30,000
3 $31,000 to $40,000
4 $41,000 to $50,000
5 $51,000 or more
8 Don’t know
9 Prefer not to answer
S9. In what ZIP Code do you currently live? ______________
S10. Which do you consider yourself to be?
1 Gay, homosexual, lesbian, or same gender loving
2 Bisexual
3 Straight or heterosexual
4 Queer
5 Pansexual
4 Other [Specify: ]
5 None of the above/Unsure
9 Prefer not to answer
S11. 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 12 months?
1 Yes
2 No
9 Prefer not to answer
S12. 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 S15]
8 Don’t know [SKIP TO S15]
9 Prefer not to answer [SKIP TO S15]
S13. What was the result of your most recent HIV test?
1 I tested positive for HIV
2 I tested negative for HIV
3 My results were unclear
8 I never got my results/Don’t know
9 Prefer not to answer
S13a. [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
S14. Do you currently have a main sexual partner—that is, a partner you would call your spouse, girlfriend/boyfriend, significant other, or life partner?
1 Yes
2 No [SKIP TO S16]
9 Prefer not to answer
S15. What is your main partner’s HIV status?
1 My last sexual partner is HIV negative
2 My last sexual partner is HIV positive
3 My last sexual partner has not been tested for HIV
8 Don’t know/my last partner has not told me their HIV status
9 Prefer not to answer
S16. What is your last sexual partner’s HIV status?
1 My last sexual partner is HIV negative
2 My last sexual partner is HIV positive
3 My last sexual partner has not been tested for HIV
8 Don’t know/my last partner has not told me their HIV status
9 Prefer not to answer
If ineligible – Closing:
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. These reasons were decided on earlier by the researchers. We value your interest in this research study. Thank you for being willing to help us.
If eligible – Invitation:
Thank you for answering these questions. This survey is part of a study on behalf of the Centers for Disease Control and Prevention (CDC) regarding [INSERT TOPIC], and we would like to hear your views. The survey should take no longer than 30 minutes to complete. Your answers will be kept private to the extent allowed by law. It is your choice to answer the questions, and you can stop at any time. As a token of appreciation for completing and submitting the entire survey, you will receive [INSERT AMOUNT]. This is an important effort and we appreciate your assistance.
Would you like to participate in this survey?
1 Yes [CONTINUE]
2 No [INELIGIBLE]
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | akj8 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-20 |