Form 0920-25-0177 Follow Up Phone Call 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 4e

Follow Up Phone Call Survey

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)

Follow-up Calls

GAIN

Page 1

Research ID

What aim was this participant in? 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) Madison Clinic Aim 5 (POC NAT Comparison)

Was the participant newly diagnosed with HIV at their Yes

GAIN study visit? (a true positive, not a false No positive)

Date of the 1st Attempt at the Month 1 Call

Were you able to successfully contact the participant Yes

on the 1st call attempt? No

Team member initials MM

CC ACH

Date of the 2nd Attempt at the Month 1 call

Were you able to successfully contact the participant Yes

on the 2nd call attempt? No

Team member initials MM

CC ACH

Date of the 3rd Attempt at the Month 1 call

Were you able to successfully contact the participant Yes

on the 3rd call attempt? No

Team member initials MM

CC ACH

Did the participant start using PrEP since their GAIN Yes

study visit? No

Not able to reach participant after 3 tries Participant was already on PrEP at their GAIN visit (include PrEP start in the notes)

When did the participant start PrEP? Please enter a date in MM/DD/YYYY format.

If the day portion ("DD") is unknown, please enter "99" in its place.

(Format: MM/DD/YYYY)

Is this participant engaged in HIV care? Yes No

Not able to reach participant after 3 tries

Is this participant taking antiretroviral therapy Yes

(ART)? No

Does the participant know their viral load? Yes No

Is the participant's viral load undetectable? Yes No

Does not know

Participant said they did not know their viral load but know they are undetectable. Please confirm these responses.

Does the participant know when their viral load first Yes

became undetectable? No

When did the participant first become undetectable? Please enter a date in MM/DD/YYYY format.

If the day portion ("DD") is unknown, please enter "99" in its place.

(Format: MM/DD/YYYY)

Is this participant currently engaged in HIV care? Yes No

Not able to reach participant after 3 tries

Please link this participant to HIV care.

Is this participant taking antiretroviral therapy Yes

(ART)? No

Does the participant know their viral load? Yes No

Is the participant's viral load undetectable? Yes No

Does not know

Participant said they did not know their viral load but know they are undetectable. Please confirm these responses.

Does the participant know when their viral load first Yes

became undetectable? No

When did the participant first become undetectable?

Please enter a date in MM/DD/YYYY format. (Format: MM/DD/YYYY)

If the day portion ("DD") is unknown, please enter "99" in its place.

Date of the 1st Attempt at the Month 3 Call

Were you able to successfully contact the participant Yes

on the 1st call attempt? No

Team member initials MM

CC ACH

Date of the 2nd Attempt at the Month 3 call

Were you able to successfully contact the participant Yes

on the 2nd call attempt? No

Team member initials MM

CC ACH

Date of the 3rd Attempt at the Month 3 call

Were you able to successfully contact the participant Yes

on the 3rd call attempt? No

Team member initials MM

CC ACH

Did the participant start using PrEP since their GAIN Yes

study visit? No

Not able to reach participant after 3 tries Participant was already on PrEP at their GAIN visit (include PrEP start in the notes)

When did the participant start PrEP? Please enter a date in MM/DD/YYYY format.

If the day portion ("DD") is unknown, please enter "99" in its place.

(Format: MM/DD/YYYY)

Is this participant engaged in HIV care? Yes No

Not able to reach participant after 3 tries

Is this participant taking antiretroviral therapy Yes

(ART)? No

Does the participant know their viral load? Yes No

Is the participant's viral load undetectable? Yes No

Does not know

Participant said they did not know their viral load but know they are undetectable. Please confirm these responses.

Does the participant know when their viral load first Yes

became undetectable? No

When did the participant first become undetectable? Please enter a date in MM/DD/YYYY format.

If the day portion ("DD") is unknown, please enter "99" in its place.

(Format: MM/DD/YYYY)

Is this participant currently engaged in HIV care? Yes No

Not able to reach participant after 3 tries

Please link this participant to HIV care.

Is this participant taking antiretroviral therapy Yes

(ART)? No

Does the participant know their viral load? Yes No

Is the participant's viral load undetectable? Yes No

Does not know

Participant said they did not know their viral load but know they are undetectable. Please confirm these responses.

Does the participant know when their viral load first Yes

became undetectable? No

When did the participant first become undetectable?

Please enter a date in MM/DD/YYYY format. (Format: MM/DD/YYYY)

If the day portion ("DD") is unknown, please enter "99" in its place.

Date of the 1st Attempt at the Month 6 Call

Were you able to successfully contact the participant Yes

on the 1st call attempt? No

Team member initials MM

CC ACH

Date of the 2nd Attempt at the Month 6 call

Were you able to successfully contact the participant Yes

on the 2nd call attempt? No

Team member initials MM

CC ACH

Date of the 3rd Attempt at the Month 6 call

Were you able to successfully contact the participant Yes

on the 3rd call attempt? No

Team member initials MM

CC ACH

Did the participant start using PrEP since their GAIN Yes

study visit? No

Not able to reach participant after 3 tries Participant was already on PrEP at their GAIN visit (include PrEP start in the notes)

When did the participant start PrEP? Please enter a date in MM/DD/YYYY format.

If the day portion ("DD") is unknown, please enter "99" in its place.

(Format: MM/DD/YYYY)

Is this participant engaged in HIV care? Yes No

Not able to reach participant after 3 tries

Is this participant taking antiretroviral therapy Yes

(ART)? No

Does the participant know their viral load? Yes No

Is the participant's viral load undetectable? Yes No

Does not know

Participant said they did not know their viral load but know they are undetectable. Please confirm these responses.

Does the participant know when their viral load first Yes

became undetectable? No

When did the participant first become undetectable? Please enter a date in MM/DD/YYYY format.

If the day portion ("DD") is unknown, please enter "99" in its place.

(Format: MM/DD/YYYY)

Is this participant currently engaged in HIV care? Yes No

Not able to reach participant after 3 tries

Please link this participant to HIV care.

Is this participant taking antiretroviral therapy Yes

(ART)? No

Does the participant know their viral load? Yes No

Is the participant's viral load undetectable? Yes No

Does not know

Participant said they did not know their viral load but know they are undetectable. Please confirm these responses.

Does the participant know when their viral load first Yes

became undetectable? No

When did the participant first become undetectable?

Please enter a date in MM/DD/YYYY format. (Format: MM/DD/YYYY)

If the day portion ("DD") is unknown, please enter "99" in its place.

Notes