Reruiter Defriefing Form - English

Form Approved

OMB No. 0920-XXXX

Expiration Date: XX/XX/XXXX

Barriers and Facilitators to Expanding the NHBS to Conduct HIV Behavioral Surveillance Among Transgender Women (NHBS-Trans)

Attachment #7a

Recruiter Debriefing Form (English)

Privacy Act Statement:

This information is collected under the authority of the Public Health Service Act, Section 301, "Research and Investigation," (42 U.S.C. 241); and Sections 304, 306 and 308(d) which discuss authority to maintain data and provide assurances of confidentiality for health research and related activities (42 U.S.C. 242 b, k, and m(d)).  This information is also being collected in conjunction with the provisions of the Government Paperwork Elimination Act and the Paperwork Reduction Act (PRA). This information will only be used by the Centers for Disease Control and Prevention (CDC) staff to field test a needs assessment regarding HIV risk behaviors, gaps and barriers to services, and other experiences of transgender women within racial and ethnic minority populations in 9 U.S. cities with high burden of HIV.

Public reporting burden of this collection of information is estimated to average 2 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)

National HIV Behavioral Surveillance System: Recruiter Debriefing Form (English)

RQ1. How many of the coupons did you give out?

[Refused= 7, Don’t Know= 9] ___

RQ2. Has anyone refused the coupons?

No………………….……………………………  0

Yes………………………………………………  1

If RQ2 = 0, skip to END.

RQ3a. How many of those who refused coupons many were Hispanic or Latino? ___

RQ3b. What is the race of those who refused coupons? That is…

a. How many were American Indian or Alaska Native? ___

b. How many were Asian? ___

c. How many were Black or African American? ___

d. How many were Native Hawaiian or Pacific Islander? ___

e. How many were white? ___

RQ4. Which of the following are reasons that people who refused gave you about why they did not take a coupon? [Read each one. Check all that apply.]

They didn’t have time…………….……….……... 1

They didn’t live in the area………………............. 2

They didn’t trust you (recruiter)..…………........... 3

They don’t like research/surveys……………….... 4

They already participated in this survey…..…....... 5

They didn’t want to be identified as transgender… 6

They weren’t eligible………….………………..... 7

Some other reason (specify: __________)…..…... 8

Refused………………………………......…..…..  77

Don't know.……………..………….……….........  99