Form 0920-25-0177 Study Visit Survey

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 4c

Study Visit Survey

Public reporting burden of this collection of information is estimated to average 15 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)

Study Visit Survey

Study ID

Study ID does not match. Please double-check and re-enter.

Visit Type HIV testing

PEP

PrEP start

PrEP persistence HIV-positive (RCT)

HIV-positive (Gay City)

Which study group was this person randomized to? Standard of Care POC NAT

HIV status at start of visit negative/unknown positive

Please confirm visit type and/or HIV status. The two fields currently do not match.

Do you want to participate in an additional survey, Yes

which will be sent to you via email? (This survey will No only be sent if you have negative point-of-care HIV

test results.)

Form Approved

OMB No. 0920-1357

Expiration Date: XX\XX\XXXX

Public reporting burden of this collection of information is estimated to average 20 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)

American Indian or Alaska Native

Enter, for example, Navajo Nation, Blackfeet Tribe of

the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome

Eskimo Community, Aztec, Maya, etc.

Asian - provide details below.
	Chinese Filipino Korean	Asian Indian Vietnamese Japanese
Enter, for example, Pakistani, Hmong, Afghan, etc.

Black or African American - provide details below.

African American Jamaican Haitian Nigerian

Ethiopian Somali

Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc.

Hispanic or Latino - provide details below.
	Mexican Salvadoran Dominican	Puerto Rican Cuban Guatemalan
Enter, for example, Columbian, Honduran, Spaniard, etc.

Middle Eastern or North African - provide details below.

Lebanese Iranian

Egyptian Syrian Iraqi Israeli

Enter, for example, Moroccan, Yemeni, Kurdish, etc.

Native Hawaiian or Pacific Islander - provide details below.

Native Hawaiian Samoan Chamorro Tongan

Fijian Marshallese

Enter, for example, Chuukese, Palauan, Tahitian, etc.

White - provide details below.

English German

Irish Italian Polish Scottish

Enter, for example, French, Swedish, Norwegian, etc.

What is your sex? Male

Female

Do you have health insurance? Yes, I have public insurance (i.e. Apple health, Medicaid, Medicare)

Yes, I have private insurance

Yes, I have something different (i.e. VA, DoD, other)

No, I do not have any health insurance Not sure

What is your health insurance type?

What is the highest grade in school you completed? Less than high school

Some high school

High school diploma or GED

Some college, Associate's degree, or Technical degree

College graduate

Post graduate or professional school I prefer not to answer

Where have you been living most of the time during the In my own home or apartment

past 30 days? In the home/apartment of friends/family (couch surfing, I am not on the lease)

Supportive housing (housing with additional services onsite, like a case manager)

Single room occupancy hotel (SRO) Transitional housing

Overnight shelter

In a tent or encampment, on the street or in a car Other

Where have you been living most of the time during the past 30 days?

Never Yes

Cannabis (marijuana, pot, grass, hash, etc.)

Cocaine (coke, crack, etc.)

Methamphetamine (speed, crystal meth, ice, etc.)

Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)

Opioids (heroin, opium, fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin])

Methadone or buprenorphine Other substances

Injected Smoked Ingested Other

Cannabis (marijuana, pot, grass, hash, etc.)

Cocaine (coke, crack, etc.)

Methamphetamine (speed, crystal meth, ice, etc.)

Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)

Opioids (heroin, opium, fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin])

Methadone or buprenorphine Other substances

Please specify the other substances you have used in the previous three months:

Have you ever used HIV pre-exposure prophylaxis, or No, I have never taken PrEP

PrEP? PrEP is a pill to prevent getting HIV. Yes, I have previously taken PrEP but do not use it now

Yes, I am currently using PrEP

When did you last stop taking PrEP? Please enter a

month and year in MM/YYYY format. If you cannot remember the month, please just enter the year. (MM/YYYY)

Have you ever taken HIV antiretroviral therapy, or No, I have never taken ART

ART? ART is a medication to treat HIV. Yes, I have previously taken ART but am not currently taking it

Yes, I am currently on ART

Thank you for your responses! Please return the laptop to study staff.