Form 0920-24CB Patient Eligibility Screener_English

Form approved

OMB # 0920-####

Exp. date MM/DD/YYYY

ATTACHMENT 6a

Pre-Exposure Survey:

Eligibility Screener, English

Thank you for your interest in participating in this study. The purpose of this study is to learn whether different types of decision aid tools can help men make informed decisions about prostate cancer screening. This study can be a great way for you to learn more about prostate cancer screening and talk to your primary care provider about your options. We are partnering with your primary care provider, Dr. [NAME] on this study about prostate cancer screening.

If you feel you have been contacted for this study in error, please let us know. If you would like to remove your name from our contact list for future research studies, please contact us by phone [PHONE #] or email [EMAIL].

If you choose to participate in this study, you will be assigned to one of three groups. Each group will receive a different type of educational material about prostate cancer screening. Depending on which group you are in, the study will require completion of up to four surveys or brief, live discussions over a period of six months. These will be conducted through secure, web-based links and telephone. Surveys will take no more than 20 minutes to complete. If you are selected for a live discussion, that will last about 60 minutes. There is no cost for participation in the study. If you agree to participate, you will receive a gift card for each survey or discussion you complete as a thank you for your time and effort.

Today, we are screening people for eligibility for this study. Your participation in this screening process is completely voluntary and requires 5-8 minutes of your time to answer questions. Your answers are completely anonymous and confidential. If you meet the eligibility criteria outlined for this study, you will immediately be asked to complete a brief survey. Please reach out to the study manager, Danielle Nielsen at Danielle.Nielsen@icf.com, with any questions before, during, or after completing this screener.

First, we’d like to confirm your eligibility to participate in this study. Please complete the questions below.

1. Are you between the ages of 55-69 years?

• Yes

• No (exclude)

2. What was your assigned sex at birth?

• Male

• Female (exclude)

• Prefer not to disclose (exclude)

3. Do you have access to the internet?

• Yes

• No (exclude)

4. Do you have a valid email address?

• Yes

• No (skip to Q5)

5. Do you have a phone number with SMS (text message) capabilities?

• Yes

• No (exclude if also answered no to Q4)

6. Do you have an upcoming general health exam visit with your health care provider?

• Yes

• No (exclude)

7. Are you interested in participating in this study?

• Yes [move on to pre-exposure survey]

• No [skip to exit screen]

NOTE FOR PROGRAMMING: Once eligible participants complete Questions 1 through 7, they should move directly to the pre-exposure survey.

Public reporting burden of this collection of information is estimated to average 8 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: PRA (0920-####).