Form 0920-25-0177 Screen and Link

Form Approved

OMB No. 0920-1357

Expiration Date: XX\XX\XXXX

The Greater Access and Impact with NAT (GAIN) Study: Improving HIV Diagnosis, Linkage to Care, and Prevention Services with HIV Point-of-Care Nucleic Acid Tests (NATs)

Attachment 4a

Screen and Link

Public reporting burden of this collection of information is estimated to average 5 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 (0920-1357)

ID Link

GAIN

Page 1

Research ID

Research ID 2

Research IDs entered do not match. Please double-check and re-enter.

Study visit date (today)

Study Staff Initials ACH

JL LN LV MM CC

GAIN Study aim Gay City Aim 1 (Testing, PEP, PrEP)

Gay City Aim 3 (HIV+)

Madison Clinic Aim 1 (Testing, PEP, PrEP) Madison Clinic Aim 3 (Randomized Trial)

Aim 1 Seattle's LGB Center Eligibility Check: Person is HIV negative/status unknown

Person is 18 years of age or older

Person is able to read and speak English

Person is at the Center for an HIV/STI Testing or PrEP visit

If person is at an HIV/STI testing, confirmed in InSync that they have not participated in GAIN before (or N/A - PrEP visit)

Eligibility Checklist not satisfied. Please confirm participant eligibility.

Aim 3 Seattle's LGB Center Eligibility Check: Person is HIV positive

Person is 18 years of age or older

Person is able to read and speak English

Appointment time is Tues - Thurs anytime or Fri before 4pm (cannot recruit after 4pm Fri or Sat)

Eligibility Checklist not satisfied. Please confirm participant eligibility.

Aim 1 Madison Eligibility Check: Person is HIV negative/status unknown Person is 18 years of age or older

Person is able to read and speak English

Person is at Madison for an HIV/STI Testing, nPEP, or PrEP visit

If person is at an HIV/STI testing or PEP visit, confirmed in Epic that they have not participated in GAIN before (or N/A - PrEP visit)

Eligibility Checklist not satisfied. Please confirm participant eligibility.

Aim 3 Madison Clinic Eligibility check: Person is HIV positive

Person is 18 years of age or older

Person is able to read and speak English

Person is seeing a provider who is able to deliver adherence intervention (Mod Provider)

Person has not participated in DETECT or GAIN Aim 3 before, confirmed in Epic

Was this a Madison Clinic patient or Mod Clinic Madison Clinic patient

patient? Mod Clinic patient

Eligibility Checklist not satisfied. Please confirm participant eligibility.

Consent Process Check Reviewed Consent form and checked for participant understanding

Completed ROI Completed HIPAA

Please complete consent process.

Do you want to randomize this participant? No Yes

Randomization study arm Standard of Care

POC NAT/Behavioral Intervention

Did the participant agree to take the longer survey Yes

that will be emailed to them by Lisa or Lauren? No

Not offered

Not eligible (does not have email)

Patient Name

Patient Date of Birth (MM-DD-YYYY)

(Format: MM-DD-YYYY)

[Calculated variable] Age

Please check that participant date of birth is correct.

Patient Phone Number

Patient Email

Patient Email (second entry)

Emails entered do not match. Please double-check and re-enter.

Patient MRN

Patient MRN (second entry)

MRNs entered do not match. Please double-check and re-enter.

Optional comments/observations (please don't include any identifying information)

Refer to paper visit checklist and follow steps to complete study visit.