Eligibility screening form

Form Approved
OMB No. 0920-xxxx
Expiration Date: XX/XX/XXXX

Injection Drug Use Surveillance Project

Attachment # 3
Eligibility Screening Form

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) and staff at the University of Washington to develop
a surveillance system to monitor drug use risk and prevention behaviors and the infectious
disease consequences of high-risk drug use in syringe services programs (SSPs) in rural and
urban areas the US.

Public reporting burden of this collection of information is estimated to average 5 minutes
to screen and assess for eligibility in order to partake in survey. 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)

Confidential

Page 1 of 265

IDU Surveillance Questionnaire
Please complete the survey below.

“Public reporting burden of this collection of information is estimated to average 30 minutes
per survey, including the time for reviewing instructions, administering questions and
entering responses. 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).”
IE1. INTERVIEWER: Please enter today's date
(mm/dd/yyyy):

02/19/2020 4:18pm

__________________________________

projectredcap.org

Confidential
Page 2 of 265

IE2. INTERVIEWER: Please enter the current time
(hh:mm) using a 24-hour clock. Example: 1:30pm
should be entered as 13:30.

02/19/2020 4:18pm

__________________________________

projectredcap.org

Confidential
Page 3 of 265

IE3. INTERVIEWER: Interviewer ID:

02/19/2020 4:18pm

__________________________________

projectredcap.org

Confidential
Page 4 of 265

IE4. INTERVIEWER: City (SSP location):

02/19/2020 4:18pm

[CITY 1]
[CITY 2]
[CITY 3]

projectredcap.org

Confidential
Page 5 of 265

IE5. INTERVIEWER: Participant ID:

02/19/2020 4:18pm

__________________________________
(Must be 4 digits)

projectredcap.org

Confidential
Page 6 of 265

IE6. Please copy the following unique Survey ID in
the text box:
[SSPCITY:value] [PID:value]

02/19/2020 4:18pm

__________________________________
(Do not add any spaces.)

projectredcap.org

Confidential
Page 7 of 265

IE7. INTERVIEWER: Is [SURID] correct?

02/19/2020 4:18pm

No
Yes

projectredcap.org

Confidential
Page 8 of 265

IE8. INTERVIEWER: Field Site ID:

02/19/2020 4:18pm

__________________________________

projectredcap.org

Confidential
Page 9 of 265

IE9. INTERVIEWER: Was the respondent selected from
the syringe exchange program?

02/19/2020 4:18pm

No
Yes

projectredcap.org

Confidential
Page 10 of 265

READ: "I'd like to thank you again for your interest in this health survey. Remember that all information you give me
will be kept private and I will not ask for your name. Most people have never been in an interview like this one. Some
questions may sound awkward, but I need to read them as worded so everyone in the study is asked the same
questions. First, I will ask you a few questions about yourself and then the computer will determine if you have been
selected to participate in the health survey."

02/19/2020 4:18pm

projectredcap.org

Confidential
Page 11 of 265

HIDDEN, AUTOMATIC CALCULATION: Start time of
eligibility screener

02/19/2020 4:18pm

__________________________________

projectredcap.org

Confidential
Page 12 of 265

ES1a. What is your month and year of birth?
[INTERVIEWER: FIRST ENTER MONTH OF BIRTH]

02/19/2020 4:18pm

January
February
March
April
May
June
July
August
September
October
November
December
Don't Know
Refuse to Answer

projectredcap.org

Confidential
Page 13 of 265

ES1b. [INTERVIEWER: ENTER YEAR OF BIRTH]

02/19/2020 4:18pm

__________________________________
(IF DON'T KNOW OR REFUSED, LEAVE BLANK)

projectredcap.org

Confidential
Page 14 of 265

DOB -- HIDDEN CALCULATION: Create concatenated date
of birth variable: DOB_M, “/”, “15”,
“/”, DOB_Y. Impute the 15th day of the month to
create a date variable that we can use in
calculations.

02/19/2020 4:18pm

__________________________________

projectredcap.org

Confidential
Page 15 of 265

AGE1 -- HIDDEN CALCULATION: Calculate age from date
of birth (DOB)

02/19/2020 4:18pm

__________________________________

projectredcap.org

Confidential
Page 16 of 265

AGE2 -- HIDDEN CALCULATION: Calculate age from date
of birth (DOB), then subtract 1 year

02/19/2020 4:18pm

__________________________________

projectredcap.org

Confidential
Page 17 of 265

ES1c. So, you are [AGE1] years old. Is that correct?

02/19/2020 4:18pm

No
Yes

projectredcap.org

Confidential
Page 18 of 265

ES1d. So, you are [AGE2] years old. Is that correct?

02/19/2020 4:18pm

No
Yes

projectredcap.org

Confidential
Page 19 of 265

AGE -- HIDDEN CALCULATION: Calculated age, confirmed
by R

02/19/2020 4:18pm

__________________________________

projectredcap.org

Confidential
Page 20 of 265

ES2. Do you consider yourself to be Hispanic,
Latino/a, or Spanish origin?

02/19/2020 4:18pm

No
Yes
Don't Know
Refuse to Answer
(If necessary, say "Just tell me Yes or No.")

projectredcap.org

Confidential
Page 21 of 265

[GIVE RESPONDENT FLASHCARD A.]
ES3. Which racial group or groups do you consider
yourself to be in? You may choose more than one
option.
[READ choices. CHECK ALL that apply.]

02/19/2020 4:18pm

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Don't Know
Refuse to Answer
Not Applicable

projectredcap.org

Confidential
Page 22 of 265

[GIVE RESPONDENT FLASHCARD B.]
ES4. What best describes your gender? You may choose
more than one option.
[READ choices. CHECK ALL that apply.]

02/19/2020 4:18pm

Man
Woman
Genderqueer/non-binary
Trans man
Trans woman
Other gender not listed
Don't Know
Refuse to Answer

projectredcap.org

Confidential
Page 23 of 265

ES4spec. INTERVIEWER: What best describes your
gender?

02/19/2020 4:18pm

__________________________________

projectredcap.org

Confidential
Page 24 of 265

ES5. What was your sex at birth?
[DO NOT READ choices.]

02/19/2020 4:18pm

Male
Female
Intersex/ambiguous
Don't Know
Refuse to Answer

projectredcap.org

Confidential
Page 25 of 265

ES6. How well do you speak English?
[READ choices.]

02/19/2020 4:18pm

Very well
Well
Not well
Not at all
Don't Know
Refuse to Answer

projectredcap.org

Confidential
Page 26 of 265

READ: "Now I am going to ask you about experiences you may have had with injecting drugs. This means injecting
drugs yourself or having someone who is not a healthcare provider inject you with a needle, either in your vein,
under the skin, or in the muscle.
Please only think about drugs you may have gotten without a prescription from your doctor or other healthcare
provider, like heroin, methamphetamine, and drugs like Oxycontin. Please also think about drugs that were
prescribed to you, but you used them in ways other than instructed by your doctor or healthcare provider."

02/19/2020 4:18pm

projectredcap.org

Confidential
Page 27 of 265

ES7. Have you ever in your life injected any drugs?

02/19/2020 4:18pm

No
Yes
Don't Know
Refuse to Answer

projectredcap.org

Confidential
Page 28 of 265

ES8a. When was the last time you injected any drug?
That is, how many days or months or years ago did
you last inject?
[INTERVIEWER: If today, enter "0"]

02/19/2020 4:18pm

__________________________________
(IF DON'T KNOW OR REFUSED, LEAVE BLANK)

projectredcap.org

Confidential
Page 29 of 265

ES8b. [INTERVIEWER: Was this days or months or
years?]

02/19/2020 4:18pm

Days
Months
Years

projectredcap.org

Confidential
Page 30 of 265

E_INJ6 -- HIDDEN CALCULATION: injected in last 6
months

02/19/2020 4:18pm

__________________________________

projectredcap.org

Confidential
Page 31 of 265

ES9. In the past 6 months, which drugs have you injected? Please say "yes" or "no" to each
drug I mention. [READ choices. CHECK ALL that apply.]
No

Yes

Don't Know

Speedball, which is heroin and
cocaine together
Goofball, which is heroin and
methamphetamine together
Fentanyl, by itself or in
combination with other drugs
Heroin, by itself
Methamphetamine, by itself,
also known as meth or speed
Powder cocaine, by itself
Crack cocaine, by itself
Painkillers, such as Oxycontin,
Dilaudid, or Percocet
Benzodiazepines or other
downers, such as Valium, Xanax,
or Klonopin

02/19/2020 4:18pm

projectredcap.org

Refuse to Answer

Confidential
Page 32 of 265

ES10. In the past 6 months, have you injected
methadone?

02/19/2020 4:18pm

No
Yes
Don't Know
Refuse to Answer

projectredcap.org

Confidential
Page 33 of 265

ES11. In the past 6 months, have you injected
buprenorphine, also known as Suboxone or Subutex?

02/19/2020 4:18pm

No
Yes
Don't Know
Refuse to Answer

projectredcap.org

Confidential
Page 34 of 265

ES12. Are there any other drugs you have injected in
the past 6 months?

02/19/2020 4:18pm

No
Yes
Don't Know
Refuse to Answer

projectredcap.org

Confidential
Page 35 of 265

ES12spec. INTERVIEWER: Specify other injection drug.

02/19/2020 4:18pm

__________________________________

projectredcap.org

Confidential
Page 36 of 265

ES13. Which drug do you inject most often?
[DO NOT READ choices.]

02/19/2020 4:18pm

Speedball, which is heroin and cocaine together
Goofball, which is heroin and methamphetamine
together
Fentanyl, by itself or in combination with other
drugs
Heroin, by itself
Methamphetamine, by itself, also known as meth or
speed
Powder cocaine, by itself
Crack cocaine, by itself
Painkillers, such as Oxycontin, Dilaudid, or
Percocet
Benzodiazepines or other downers, such as Valium,
Xanax, or Klonopin
Methadone
Buprenorphine, also known as Suboxone or Subutex
Something else
Don't Know
Refuse to Answer

projectredcap.org

Confidential
Page 37 of 265

ES13spec. INTERVIEWER: Specify other injection drug.

02/19/2020 4:18pm

__________________________________

projectredcap.org

Confidential
Page 38 of 265

READ: "Now I am going to ask you about experiences you may have had with drugs that you did not inject. This
includes times that you may have smoked, snorted, inhaled, or ingested drugs.
Please only think about drugs you may have gotten without a prescription from your doctor or other medical
provider, like heroin, methamphetamine, and drugs like Oxycontin. Please also think about drugs that were
prescribed to you but you used them in ways other than instructed by your doctor or healthcare provider."

02/19/2020 4:18pm

projectredcap.org

Confidential
Page 39 of 265

ES14. Have you ever in your life used any drugs that
you did not inject?

02/19/2020 4:18pm

No
Yes
Don't Know
Refuse to Answer

projectredcap.org

Confidential
Page 40 of 265

ES15a. When was the last time you used any drug that
you did not inject? That is, how many days or months
or years ago did you last use drugs? [INTERVIEWER:
If today, enter "0"]

02/19/2020 4:18pm

__________________________________
(IF DON'T KNOW OR REFUSED, LEAVE BLANK)

projectredcap.org

Confidential
Page 41 of 265

ES15b. [INTERVIEWER: Was this days or months or
years?]

02/19/2020 4:18pm

Days
Months
Years

projectredcap.org

Confidential
Page 42 of 265

E_DRG6 -- HIDDEN CALCULATION: used drug in last 6
months

02/19/2020 4:18pm

__________________________________

projectredcap.org

Confidential
Page 43 of 265

ES16. In the past 6 months, which drugs did you use that did NOT inject? Please say "yes" or
"no" to each drug I mention.
No

Yes

Don't Know

Marijuana
Methamphetamine, also known
as meth or speed
Crack cocaine
Powder cocaine
Benzodiazepines or other
downers, such as Valium, Xanax,
or Percocet
Painkillers, such as Oxycontin,
Dilaudid, or Percocet
X or ecstasy (MDMA)
Heroin
Fentanyl, by itself or in
combination with other drugs
Adderall, Ritalin, or other
commonly prescribed stimulants

02/19/2020 4:18pm

projectredcap.org

Refuse to Answer

Confidential
Page 44 of 265

ES17. In the past 6 months, have you used methadone
that was not prescribed or not taken as prescribed?

02/19/2020 4:18pm

No
Yes
Don't Know
Refuse to Answer

projectredcap.org

Confidential
Page 45 of 265

ES18. In the past 6 months, have you used
buprenorphine, also known as Suboxone or Subutex,
that was not prescribed or not taken as prescribed?

02/19/2020 4:18pm

No
Yes
Don't Know
Refuse to Answer

projectredcap.org

Confidential
Page 46 of 265

ES19. Are there any other drugs you have used and did
not inject in the past 6 months?

02/19/2020 4:18pm

No
Yes
Don't Know
Refuse to Answer

projectredcap.org

Confidential
Page 47 of 265

ES19spec. INTERVIEWER: Specify other non-injection
drug.

02/19/2020 4:18pm

__________________________________

projectredcap.org

Confidential
Page 48 of 265

ES20. INTERVIEWER: Is this person alert and capable
of completing the survey in English?

02/19/2020 4:18pm

No
Yes

projectredcap.org

Confidential
Page 49 of 265

ES21. INTERVIEWER: Specify reason person not able to
complete the interview:

Not able to understand or give permission
Cannot speak and understand English

[CHECK ALL that apply.]

02/19/2020 4:18pm

projectredcap.org

Confidential
Page 50 of 265

ES22. INTERVIEWER: Has this person participated in
this study before?

02/19/2020 4:18pm

No
Yes

projectredcap.org

Confidential
Page 51 of 265

ES23. INTERVIEWER: Did your field supervisor tell you
that this person cannot complete the survey for some
other reason?

02/19/2020 4:18pm

No
Yes

projectredcap.org

Confidential
Page 52 of 265

READ: "We've finished the first series of questions. Now the computer will determine whether you've been selected
to participate in the survey."

02/19/2020 4:18pm

projectredcap.org

Confidential
Page 53 of 265

Hidden, calculated variable: EL_IDU = IF((AGE>17 &
CAPABLE=1 & E_PART=0 & SUPERV=0 & (E_INJ6=1 OR
(E_DRG6=1 AND E_DRGEL=1)),1,0)

02/19/2020 4:18pm

__________________________________

projectredcap.org

Confidential
Page 54 of 265

If R NOT eligible for cycle, READ: "Unfortunately, the computer has not selected you to participate in the health
survey. Thank you for your time." Then go to STOP.

02/19/2020 4:18pm

projectredcap.org

Confidential
Page 55 of 265

ES24. INTERVIEWER: This participant was not selected
for this health survey. Please click stop to end
survey.

02/19/2020 4:18pm

Stop

projectredcap.org

Confidential
Page 56 of 265

If R eligible for cycle, READ: "Congratulations! The computer has selected you to participate in the health survey. Let
me tell you about it."
[INTERVIEWER: Proceed with the permission process.]

02/19/2020 4:18pm

projectredcap.org

Confidential
Page 57 of 265

CN1. Do you agree to take part in the survey?

02/19/2020 4:18pm

No
Yes

projectredcap.org

Confidential
Page 58 of 265

CN2. Do you agree to HIV counseling and testing?

02/19/2020 4:18pm

No
Yes

projectredcap.org

Confidential
Page 59 of 265

CN3. Do you agree to hepatitis C testing?

02/19/2020 4:18pm

No
Yes

projectredcap.org

Confidential
Page 60 of 265

CN4. Do you agree to let us store some of your blood
for future testing?

02/19/2020 4:18pm

No
Yes

projectredcap.org

Confidential
Page 61 of 265

HIDDEN, AUTOMATIC: End time of eligibility screener

02/19/2020 4:18pm

__________________________________

projectredcap.org