Contact Information ChiCAS Screener - English

Form Approved
OMB No: 0920-New
Exp. Date: XX/XX/XXXX

HIV prevention among Latina transgender women who have sex with men:
Evaluation of a locally developed intervention
Attachment 4a
ChiCAS Screener English

Form Approved
OMB No: 0920-New
Exp. Date: XX/XX/XXXX

In-person screening
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 privacy 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 evaluate the
efficacy of the locally developed ChiCAS HIV prevention intervention for Hispanic/Latina transgender women.
Public reporting burden of this collection of information is estimated to average 4 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)

Hi! I’m ______________ [The recruiter provides his/her full name]. I am with Triad Health Project.
We are recruiting for a research study. The purpose of this study is to implement and evaluate
ChiCAS Creando Acceso a la Salud (Girls Creating Access to Health), a small-group program
designed to reduce HIV and increase safe use of hormone therapy. You have seen the flier.
Are you interested in seeing whether you are eligible to participate in the ChiCAS study for Latina
transgender women?
[If the person says that she is not interested in being part of the research study, the recruiter
should thank her for her time.]
Good, before I take too much of your time explaining the study and scheduling a time to thoroughly
discuss the study, let me ask you a few questions to make sure you are eligible. Some of these
questions may be sensitive, but your answers will be kept private and your name will be separated
from your answers here.
[The recruiter asks the following questions and documents the answers provided. Read only the
questions outlined in Column A and denote potential participant’s response in Column B. Follow
instructions in Column C to determine whether the potential participant is eligible for that criterion
and select the correct response in Column D.]
A
Inclusion criteria

B
Answer

1) Which of the
following best
describes your
ethnicity?

1 Hispanic or Latino

2) How old are
you?

__________ years old

3) In which
language would
you consider
yourself to be
fluent?

0 Not Hispanic or
Latino

1 Only Spanish
2 More Spanish
than English
3 Both equally

C
Instructions
[If “Hispanic or Latino”, select
“Yes” in the following
Column… Otherwise, select
“No”.]
[If ≥18 years old, select “Yes”
in the following Column…
Otherwise, select “No”.]
[If “Only Spanish”, “More
Spanish than English”, or “Both
equally”, then select “Yes” in
the following Column…
Otherwise, select “No”.]

D
Eligible?
No
Yes

0

No

1

Yes

0

No

1

Yes

0

No

1

Yes

4 More English than
Spanish
5 Only English
4) What sex was
on your original
birth certificate?

0
1
2
3

Male
Female
Refused
Don’t know

[If “Male”, then select “Yes” in
the following Column…
Otherwise, select “No”.]

5) Do you currently
describe yourself
as male, female or
transgender?

0
1
2
3

Male
Female
Transgender
none of these

[If “Female” or “Transgender”,
then select “Yes” in the
following Column… Otherwise,
select “No”.]

6) What was the
result of your
recent HIV test?

0
1
2
3
4

Positive
Negative
I don’t know
Indeterminate
Never tested

[If “Positive”, select “No” in the
following Column…Otherwise,
select “Yes”.]

7) In the past 6
months, have you
had sex with a man
at least once?

0 No

8) In the past 12
months have you
participated in any
HIV prevention
intervention such
as ChiCAS, HOLA
en Grupos, or
HOLA?

0 No

1 Yes

1 Yes

[If “Yes”, then select “Yes” in
the following Column…
Otherwise, select “No”.]

0

No

1

Yes

0

No

1

Yes

0

No

0

No

1

Yes

0

No

1

Yes

1

Yes

[If “Yes”, then select “No” in the
following Column… Otherwise,
select “Yes”.]

[Now there are 2 options:]
1) [If there is a “NO” for any question in Column D, the recruiter says:]
Thanks for your help. I really appreciate your interest in this study but the information that you
have shared with us indicates that you are not eligible.
[The recruiter and the person say good-bye and leave.]
2) [If there are zero “NO” answers and 8 “YES” answers in Column D, the recruiter says:]
It looks like you are eligible to participate in the study. You will need to get tested for HIV to confirm
your eligibility. ChiCAS is a study that includes answering questions about your health and sexual
behavior two times over a 6-7 month period. It also includes participating in 2 educational sessions
that will provide you with information about PrEP, which is an HIV prevention method in which
people take a pill daily to reduce the chances that they will get HIV from an infected sex partner;
how to access transition-related healthcare services (such as hormone therapy); and how to use a
condom correctly. Since PrEP is an HIV prevention method, participants need to be HIV negative
to be part of the study, which is the reason why an HIV test will be conducted. You will receive
$30.00 for answering questions in person the first time and $40.00 for answering questions in
person the second time (if you answer questions the second time by telephone, you will receive
$30).You also will receive $40.00 for each of the 2 educational sessions you attend.

I would like to schedule a time to meet with you so that I can test you for HIV to confirm your
negative status, tell you more about the study, and obtain your consent to participate. After that,
we will give you a questionnaire to fill out.
[The recruiter and potential participant set up a time and place that offers privacy and is
convenient for the potential participant to meet, receive an HIV test, and review the consent
form and complete the baseline assessment if the potential participant chooses to participate.]
Also, could you please give me your name and number? Hold on to my number as well in case you
need to change appointment time and place. [The recruiter gives the person an appointment card.]

------------------------------------------------------------------------------------------------------------------------------NOTE TO STAFF: Please detach this page from the rest of the screening form and store in a
separate lock box when completed.
Date of recruitment:

Time of recruitment:

Name of potential participant:

Telephone number of potential
participant:

Can we leave a message at this number?

Date of appointment:

Time of appointment:

Place of appointment:

How did you hear about this study?

Voice message:
Text message:

No
0 No
0

Yes
1 Yes
1