Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX










“Community-based Organization Outcome Monitoring Projects for CBO HIV Prevention Services Clients”





Attachment 5a#

Category 1 Baseline Interview

















Public reporting burden of this collection of information is estimated to average 40 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)










General Information- to be completed by staff member


Complete the General Information section prior to administering the questionnaire.


G1. Name of the CBO (Choose one)

G2. Screener ID:

___ ___ ___ ___


G3. CBO-OMP ID:

___ ___ ___ ___


G4. Staff ID:

____________


G5. Interview date:

__ __/__ __/__ __ __ __ (MM/DD/YYYY)


G6. Interview site: (Choose one)

G7. Interview time point: (Choose one)

G8. Interview administered by: (Choose one)

G9. Was this participant first diagnosed by an HIV test funded by CBO-HPS? (Choose one)

G10. When did the participant receive the most recent referral to HIV medical care from the CBO-HPS program?

__ __/__ __/__ __ __ __ (MM/DD/YYYY)


G11. Since (MM/DD/YYYY listed above), what new CBO-HPS referrals was the participant provided? (Choose all that apply)

HIP Behavioral Interventions: (Note: this may be known by different names at each CBO.)

Linkage to Care Intervention:

Medication Adherence Support Services:

Screening and treatment for STDs, Hepatitis, and TB

Other Prevention Services

Participant Interview


Interviewer: Welcome and thank you for participating. This interview will cover a variety of topics related to your experiences with different HIV-related services. For some of these experiences, we will ask you about them during each interview. But there will be other information that we only ask you once. I want to assure you that anything you tell me will be kept private. This first interview will take approximately 30 minutes. The other interviews will be a little shorter, about 20 minutes. Feel free to stop me at any time if you have questions. Do you have any questions before we begin? Let’s get started.


Participant Demographics


Interviewer: Now, I will ask you some basic questions about yourself.


  1. Please tell me the month and year of your date of birth?

__ __/__ __ __ __ (MM/YYYY)


  1. How old are you?

__ __ __


  1. Are you: (Choose one)


  1. What is your race? (Choose all that apply)


  1. What was your sex at birth? (Don’t read responses. Choose only one.)


  1. Do you consider yourself to be male, female, or transgender? (Don’t read responses. Choose only one.)


  1. Do you think of yourself as: (Choose one)


  1. Are you attracted to other males? (Only ask if participant identifies gender as male, any transgender, and is 19 years old or younger) (Choose one)


  1. Where were you born? (Choose one)


  1. What year did you come to live in the U.S? __ __ __ __ (YYYY) (Only ask if participant indicates being born in a country other than the U.S.)


  1. Is English your first language? (Choose one)


  1. What is the highest level of education that you have completed? (Choose one)


  1. What best describes your employment status? Are you: (Choose one)


  1. Do you currently have health insurance or health care coverage? (Choose one)



  1. What kind of health insurance or coverage do you currently have? (Only ask if participant indicates currently having health care coverage.) (Choose all that apply.)



  1. What was your income last year before taxes? (Show Flashcard A to participant. Ask them to indicate which letter on the flashcard shows the correct income.) (Choose one)

  1. 0 to $417 a month OR 0 to $4,999 a year

  2. $418 to $833 a month OR $5,000 to $9,999 a year

  3. $834 to $1041 a month OR $10,000 to $12,499 a year

  4. $1042 to $1250 a month OR $12,500 to $14,999 a year

  5. $1251 to $1667 a month OR $15,000 to $19,999 a year

  6. $1668 to $2082 a month OR $20,000 to $24,999 a year

  7. $2083 to $2500 a month OR $25,000 to $29,999 a year

  8. $2501 to $2916 a month OR $30,000 to $34,999 a year

  9. $2917 to $3333 a month OR $35,000 to $39,999 a year

  10. $3334 to $4167 a month OR $40,000 to $49,999 a year

  11. $4168 to $4999 a month OR $50,000 to $59,999 a year

  12. $5000 to $6250 a month OR $60,000 to $74,999 a year

  13. $6251 or more a month OR $75,000 or more a year

  14. Decline to answer

  15. Don’t know


  1. Including yourself, how many people depend on this income?



Participant Characteristics


Interviewer: Now, I am going to ask you some questions about sex, drug use, and jail. Remember all of your responses are private.


  1. In the past 5 years, have you had oral, vaginal, or anal sex with a male? (Choose one)



  1. In the past 5 years, have you had oral, vaginal, or anal sex with a female? (Choose one)

  1. In the past 12 months, have you had vaginal or anal sex without a condom? (Only ask if participant has had oral, vaginal, or anal sex in the past 5 years) (Choose one)



  1. In the past 12 months, did a sex partner give you drugs, money, a place to stay, clothing or something else you needed in exchange for sex? (Only ask if participant has had oral, vaginal, or anal sex in the past 5 years) (Choose one)



  1. In the past 12 months, did you give a sex partner drugs, money, a place to stay, clothing or something else you needed in exchange for sex? (Only ask if participant has had oral, vaginal, or anal sex in the past 5 years) (Choose one)

  1. In the past 12 months, have you had chlamydia, gonorrhea, or syphilis? (Only ask if participant has had oral, vaginal, or anal sex in the past 5 years) (Choose one)


  1. In the past 5 years, have you shot up or injected any drugs that weren’t used for medical purposes? (Choose one)



  1. In the past 12 months, have you shared injection or drug preparation equipment to inject drugs not prescribed to you by a clinician for medical purposes? (Only ask if participant has shot up or injected drugs that weren’t used for medical purposes in the last 12 months.) (Choose one)

  1. In the last 12 months were you in jail or prison for more than 24 hours? (Choose one)


Interviewer: The next set of questions will ask you about your experiences, in general, with doctors, nurses, and other health care providers. Please tell me how strongly you disagree or agree with the following statements.


  1. I doubt that my HIV health care provider really cares about me as a person (Choose one)


  1. My HIV health care provider is considerate of my needs and puts them first (Choose one)


  1. I trust my HIV health care provider so much I always try to follow his/her advice (Choose one)


  1. If my HIV health care provider tells me something is so, then it must be true (Choose one)


  1. I sometimes distrust my HIV health care provider opinions and would like a second one (Choose one)


  1. I trust my HIV health care provider’s judgements about my medical care (Choose one)


  1. I feel my HIV health care provider does not do everything he/she should about my medical care (Choose one)


  1. I trust my HIV health care provider to put my medical needs above all other considerations when treating my medical problems (Choose one)


  1. My HIV health care provider is well-qualified to manage (diagnose and treat or make an appropriate referral) medical problems like mine (Choose one)


  1. I trust my HIV health care provider to tell me if a mistake was made about my treatment (Choose one)


  1. I sometimes worry that my HIV health care provider may not keep the information we discuss totally private (Choose one)


Previous Participant Engagement with CBO


Interviewer: This question is about your experience with [CBO]. You were referred to [PROGRAM(S) AND SERVICE(S)].

  1. Prior to those referral(s), what was your experience with [CBO]? (Choose one)

HIV Medical Care


Interviewer: Now, I’m going to ask you some questions about your experiences since receiving your HIV positive test result. Some of the questions are about the medical care for HIV infection. We will refer to HIV medical care providers and this may mean doctors, nurses, or other health care providers that deliver HIV medical care.


  1. When did you first test positive for HIV? (If they don’t remember the month or year, please ask them to provide their best estimate.)

___ ___/___ ___ ___ ___


  1. After you tested positive did someone from the health department or a health care provider offer to tell or help you tell your sex or drug use partners that they may have been exposed to HIV? (Choose one)


  1. Which of the following applies to this experience? (Choose one)


Interviewer: [CBO] referred you to HIV medical care on [insert date]. The next few questions are related to that referral.


  1. Which of the following things were you offered? (Choose all that apply, unless it’s “Only contact information….”)


  1. After you received the referral for HIV medical care (insert date), did you visit an HIV medical care provider? (Choose one)



  1. What is the date of your scheduled appointment? (Only ask if participant indicates that they have not been to their HIV medical care appointment because it has not occurred yet.If they don’t remember the day, please ask them to provide their best estimate.)

___ ___/___ ___/___ ___ ___ ___ (MM/DD/YYYY)

(Go to Previous HIV medical care, intro text at “Before receiving your referral to HIV medical care on [insert date], had you ever seen HIV medical care provider for HIV medical care? …”)



  1. What was the date you first visited an HIV medical care provider for HIV medical care after receiving the referral on (insert date)? (If they don’t remember the day or the month, please ask them to provide their best estimate.)

___ ___/___ ___/___ ___ ___ ___ (MM/DD/YYYY)


  1. Did someone from [CBO] help you with transportation to your HIV medical care appointment? (Only ask if participant attended an HIV medical care appointment based on this referral.) (Choose one)



  1. Did you want someone from [CBO] to help you with transportation to your HIV medical care appointment? (Choose one)



  1. Did someone from [CBO] go with you to your HIV medical care appointment? (Only ask if participant attended an HIV medical care appointment based on this referral.) (Choose one)



  1. Did you want someone from [CBO] to go with you to your HIV medical care appointment? (Choose one)

Interviewer: You attended a medical care appointment on [insert date]. The next set of questions will ask you about your experiences, with these specific doctors, nurses, and other HIV health care providers. For each statement, please tell me In your opinion, how often your HIV health care providers


  1. …listen carefully to you? (Choose one)


  1. … explain things in a way that you can understand? (Choose one)


  1. … show respect for what you have to say? (Choose one)


  1. … spend enough time with you? (Choose one)


Go to “Since your appointment on (insert date) did an HIV medical care provider prescribe HIV medicines?”


Interviewer: I’m going to read you a list of possible reasons people with HIV may have not gone to see their HIV medical care provider for HIV medical care.


  1. Please tell me whether or not each reason applies to you. Is one of the reasons…? (Only ask questions in this section if participant indicates “No, did not go for another reason” to the question “After you received the referral for HIV medical care did you visit an HIV medical care provider for HIV medical care?) (Choose one)


    1. …because you had difficulties scheduling an appointment?


    1. …because you couldn’t get time off of work for the appointment?



    1. …because you couldn’t find childcare?


    1. …because you didn’t think you needed to?


    1. …because you haven’t felt sick?


    1. …because you haven’t believed that HIV medicine will improve your health?


    1. …because you’ve been afraid or in denial about being HIV positive?


    1. …because you haven’t wanted anyone to know that you have HIV?


    1. …because you haven’t liked or trusted health care providers?


    1. …because of problems with money or health insurance?


    1. …because you’ve been drinking or using drugs?


    1. …because you've been depressed or been having other mental health problems?


    1. …because you’ve been physically sick or hospitalized?


    1. …because you’ve been in prison or jail?



    1. …because the HIV medical care provider is too far away?


    1. …because you haven’t found HIV medical care provider that spoke your language?


    1. …because you’ve had trouble getting transportation to an HIV medical care provider?


    1. …because you forgot?


    1. …because of some other reason(s)?


    1. If yes, please tell me the other reason(s) that you may not have gotten outpatient HIV medical care.

____________________________

  1. Of all the reasons you just gave, which is the most important one? ___ (Choose only one response a-v)


HIV Medicines


(Note: only ask if participants attended their first HIV medical care appointment from this referral.)


Interviewer: Now, I’m going to ask some questions about medicines that you may be taking for your HIV. These medicines are called HIV medicines, and are also known as antiretroviral medicines, ART, or HAART.


You went to a medical care appointment on (insert date from “What was the date you first visited HIV medical care provider for HIV medical care …”).


  1. Are you currently taking HIV medicines? (Only ask if participant was prescribed HIV medicines at this appointment) (Choose one)

Interviewer: I’m going to read you a list of possible reasons people with HIV may not be taking HIV medicines.


  1. Please tell me whether or not each reason applies to you. Is one of the reasons… (Only ask the questions in this section if participant indicates not currently taking any HIV medicines.) (Choose one)

  1. …because you have not filled your prescription yet?



  1. …because your HIV medical care provider did not give you a prescription or said you should not take HIV medicines?



  1. …because you have problems paying for or getting insurance or coverage for HIV medicines?

  1. … because you don’t think you need them?


  1. … because you think they would make you feel sick or harm you?


  1. …because HIV medicines caused side effects in the past?


  1. …because you decided not to take HIV medicines for some other reason?


  1. Please tell me the other reason that you decided not to take HIV medicines?

__________________

  1. Of all the reasons you just gave, what is the most important one? ___ (Enter only one response a-h)


  1. In the last 30 days, how much did you pay out of pocket for your HIV medicines or for HIV medical care visits? (Only ask if participant attended HIV medical care appointment through this referral). (Choose one)



Previous HIV Medical Care

Now, I’m going to ask some questions about your previous experiences with HIV medical care.


  1. Before receiving your referral to HIV medical care from [CBO] on [insert date], had you ever seen HIV medical care provider? (Choose one)


  1. Before receiving your referral to HIV medical care from [CBO] on [insert date], had you ever been prescribed HIV medicines for your HIV infection? (Choose one)


  1. Before receiving your referral to HIV medical care from [CBO] on [insert date], had you ever taken HIV medicines for your HIV infection? (Choose one)

Other CBO-HPS Referrals and Services


The questions below will be based on responses to G11. Participants will only be asked about referrals they received.


Interviewer: I am now going to ask you some questions about other referrals and services you received.


HIP Behavioral Interventions


  1. You were referred to [insert HIP behavioral intervention here]. Did you attend at least one session? (Choose one)


Interviewer: I’m going to read you a list of possible reasons people may not have attended a session.


  1. Please tell me whether or not each reason applies to you. Is one of the reasons you have not attended [insert HIP behavioral intervention here]… (Only ask questions in this section if participant did not attend at least one session of the intervention, declined to answer, or don’t know.) (Choose one)


  1. …because you couldn’t get time off of work to attend?



  1. …because you couldn’t find childcare?


  1. …because you didn’t think you needed to?


  1. …because you’ve been afraid or in denial about being HIV positive?


  1. …because you haven’t wanted anyone to know that you have HIV?


  1. …because you’ve been drinking or using drugs?


  1. …because you've been depressed or been having other mental health problems?


  1. …because you’ve been physically sick or hospitalized?


  1. …because you’ve been in prison or jail?


  1. …because the location was too far away?


  1. …because the services offered were not in your language?


  1. …because you’ve had trouble getting transportation?


  1. …because you forgot?


  1. …because of some other reason(s)?


  1. If yes, please tell me the other reason(s) that you did not attend [insert HIP behavioral intervention here].

____________________________


  1. Of all the reasons you just gave, what is the most important one? _____________(Enter one of the responses above a-o)

(If did not go to at least one session of [INTERVENTION1], go to questions for next referral.)


  1. Did you complete or graduate from [insert HIP behavioral intervention]? (Choose one)


(Repeat questions in this section for each intervention the participant was referred to.)


ARTAS

  1. You were referred to ARTAS. Did you attend at least one session? (Choose one)


Interviewer: I’m going to read you a list of possible reasons people may not have attended a session of ARTAS.


  1. Please tell me whether or not each reason applies to you. Is one of the reasons… (Only ask questions in this section if participant did not attend at least one session of ARTAS.) (Choose one)


  1. …because you couldn’t get time off of work to attend?


  1. …because you couldn’t find childcare?


  1. …because you didn’t think you needed to?


  1. …because you’ve been afraid or in denial about being HIV positive?


  1. …because you haven’t wanted anyone to know that you have HIV?


  1. …because you’ve been drinking or using drugs?


  1. …because you've been depressed or been having other mental health problems?


  1. …because you’ve been physically sick or hospitalized?


  1. …because you’ve been in prison or jail?


  1. …because the location was too far away?


  1. …because the services offered were not in your language?


  1. …because you’ve had trouble getting transportation?


  1. …because you forgot?



  1. …because of some other reason(s)?


  1. If yes, please tell me the other reason(s) that you did not attend ARTAS.

____________________________


  1. Of all the reasons you just gave, what is the most important one? ___ (Enter one of the responses above a-t)


(Go to questions for next referral.)


Medication Adherence Support Services


  1. You were referred to [insert medication adherence support service]. Did you attend at least one session? (Choose one)


Interviewer: I’m going to read you a list of possible reasons people may not have attended a session.


  1. Please tell me whether or not each reason applies to you. Is one of the reasons you have not attended [insert medication adherence support service]… (Only ask questions in this section if participant did not attend at least one session of [insert medication adherence support service].) (Choose one)


  1. …because you couldn’t get time off of work to attend?


  1. …because you couldn’t find childcare?


  1. …because you didn’t think you needed to?


  1. …because you’ve been afraid or in denial about being HIV positive?


  1. …because you haven’t wanted anyone to know that you have HIV?


  1. …because you’ve been drinking or using drugs?


  1. …because you’ve been depressed or been having other mental health problems?


  1. …because you’ve been physically sick or hospitalized?


  1. …because you’ve been in prison or jail?


  1. …because the location was too far away?


  1. …because the services offered were not in your language?


  1. …because you’ve had trouble getting transportation?


  1. …because you forgot?


  1. …because of some other reason(s)?


  1. If yes, please tell me the other reason(s) that you did not attend [insert medication adherence intervention].

____________________________


  1. Of all the reasons you just gave, what is the most important one? ___ (Enter one of the responses above a-o)


(If did not go to at least one session of [MEDICATIONADHERENCE1], go to questions for next referral.)


  1. Did you complete or graduate from [insert medication adherence support service] ? (Only ask if participant indicated having attended at least one session of medication adherence support services.) (Choose one)


(Repeat questions in this section for each medication adherence support service the participant was referred to.)


STD/Hepatits/Tuberculosis Screening and Treatment


If referred to an STD screening/treatment:


  1. You were referred to STD testing. Did you get tested? (Choose one)


Interviewer: I’m going to read you a list of possible reasons people may not have been tested for STDs.


  1. Please tell me whether or not each reason applies to you. Is one of the reasons… (Only ask questions in this section if participant was not tested for STDs.) (Choose one)

  1. …because you had difficulties scheduling an appointment?


  1. …because you couldn’t get time off of work to go to appointment?


  1. …because you couldn’t find childcare?


  1. …because you didn’t think you needed to?


  1. …because you haven’t felt sick?



  1. …because you’ve been afraid or in denial about having an STD?


  1. …because you haven’t wanted anyone to know that you have an STD?


  1. …because you haven’t liked or trusted health care providers?


  1. because of problems with money or health insurance?


  1. …because you’ve been drinking or using drugs?


  1. …because you’ve been depressed or been having other mental health problems?


  1. …because you’ve been physically sick or hospitalized?


  1. …because you’ve been in prison or jail?


  1. …because the location was too far away?


  1. …because you haven’t found an STD clinic or provider that spoke your language?


  1. …because you’ve had trouble getting transportation?


  1. …because you forgot?

  1. …because of some other reason(s)?


  1. If yes, please tell me the other reason(s) that you may not have gone to get STD testing.

____________________________


  1. Of all the reasons you just gave, what is the most important one? ___ (Enter only one response a-s)


(If did not test for any STDs, go to questions for next referral)


  1. Did you test positive for an STD? (Choose one)

  1. Did you receive treatment for at least one STD? (Choose one)

Interviewer: I’m going to read you a list of possible reasons people may not receive treatment for STDs.


  1. Please tell me whether or not each reason applies to you. Is one of the reasons… (Only ask the questions in this section if participant indicates not receiving treatment for STDs.) (Choose one)

  1. …because you have not filled your prescription yet?



  1. …because your medical care provider said you do not need treatment?



  1. …because you have problems paying for or getting insurance or coverage for treatment?

  1. …because you don’t think you need treatment?


  1. …because you think treatment would make you feel sick or harm you?


  1. …because treatment caused side effects in the past?


  1. …because you did not receive treatment for some other reason?


  1. Please tell me the other reason that you did not receive treatment?

__________________

  1. Of all the reasons you just gave, what is the most important one? ___ (Enter only one response a-h)

(If the participant did not receive treatment for STDs, go to questions for next referral)


  1. You were referred to testing for hepatitis. Did you get tested? (Choose one)


If referred to an Hepatitis screening/treatment/vaccination:


Interviewer: I’m going to read you a list of possible reasons people may not have been tested for hepatitis.


  1. Please tell me whether or not each reason applies to you. Is one of the reasons… (Only ask questions in this section if participant was not tested for hepatitis.) (Choose one)

  1. …because you had difficulties scheduling an appointment?


  1. …because you couldn’t get time off of work to go to appointment?


  1. …because you couldn’t find childcare?


  1. …because you didn’t think you needed to?


  1. …because you haven’t felt sick?


  1. …because you’ve been afraid or in denial about having hepatitis?



  1. …because you haven’t liked or trusted health care providers?

  1. …because of problems with money or health insurance?


  1. …because you’ve been drinking or using drugs?


  1. …because you’ve been depressed or been having other mental health problems?


  1. …because you’ve been physically sick or hospitalized?


  1. …because you’ve been in prison or jail?


  1. …because the location was too far away?


  1. …because you haven’t found a medical care provider that spoke your language?


  1. …because you’ve had trouble getting transportation?


  1. …because you forgot?


  1. …because of some other reason(s)?


  1. If yes, please tell me the other reason(s) that you have not gone to get tested for hepatitis.

____________________________


  1. Of all the reasons you just gave, what is the most important one? ___ (Enter only one response a-r)


(If the participant did not test for hepatitis, go to questions for next referral)


  1. Did you test positive for hepatitis? (Choose one)

  1. Did you receive treatment for hepatitis? (Choose one)

Interviewer: I’m going to read you a list of possible reasons people may not receive treatment for hepatitis.


  1. Please tell me whether or not each reason applies to you. Is one of the reasons… (Only ask the questions in this section if participant indicates not receiving treatment for hepatitis.) (Choose one)

  1. …because you have not filled your prescription yet?



  1. …because your medical care provider said you do not need treatment?



  1. …because you have problems paying for or getting insurance or coverage for treatment?

  1. …because you don’t think you need treatment?


  1. …because you think treatment would make you feel sick or harm you?


  1. …because treatment caused side effects in the past?


  1. …because you did not receive treatment for some other reason?


  1. Please tell me the other reason that you did not receive treatment?

__________________

  1. Of all the reasons you just gave, what is the most important one? ___ (Enter only one response a-p)


  1. Did you get vaccinated for hepatitis? (Choose one)

Interviewer: I’m going to read you a list of possible reasons people may not have been vaccinated for hepatitis.


  1. Please tell me whether or not each reason applies to you. Is one of the reasons… (Only ask questions in this section if participant was not vaccinated for hepatitis.) (Choose one)


  1. …because you had difficulties scheduling an appointment?


  1. …because you couldn’t get time off of work to go to appointment?


  1. …because you couldn’t find childcare?


  1. …because you didn’t think you needed to?


  1. …because you haven’t felt sick?


  1. …because your medical care provider told you should not get vaccinated?


  1. …because you haven’t liked or trusted health care providers?


  1. …because of problems with money or health insurance?


  1. …because you’ve been drinking or using drugs?


  1. …because you’ve been depressed or been having other mental health problems?


  1. …because you’ve been physically sick or hospitalized?


  1. …because you’ve been in prison or jail?


  1. …because the location was too far away?


  1. …because you haven’t found an HIV medical care provider that spoke your language?


  1. …because you’ve had trouble getting transportation?


  1. …because you forgot?


  1. …because of some other reason(s)?


  1. …because of some other reason(s)?


  1. If yes, please tell me the other reason(s) that you have not received a vaccination for hepatitis.

____________________________


  1. Of all the reasons you just gave, what is the most important one? ___ (Enter only one response a-t)


(If participant did not receive a vaccination for hepatitis, go to questions for next referral.)


If referred to an TB testing/treatment:


  1. You were referred to tuberculosis or TB testing. Did you get tested for TB ? (Choose one)

Interviewer: I’m going to read you a list of possible reasons people may not have been tested for TB.


  1. Please tell me whether or not each reason applies to you. Is one of the reasons… (Only ask questions in this section if participant was not tested for TB.) (Choose one)


  1. …because you had difficulties scheduling an appointment?


  1. …because you couldn’t get time off of work to go to appointment?


  1. …because you couldn’t find childcare?


  1. …because you didn’t think you needed to?


  1. …because you haven’t felt sick?


  1. …because you’ve been afraid or in denial about having TB?


  1. …because you haven’t liked or trusted health care providers?


  1. …because of problems with money or health insurance?


  1. …because you’ve been drinking or using drugs?


  1. …because you’ve been depressed or been having other mental health problems?


  1. …because you’ve been physically sick or hospitalized?


  1. …because you’ve been in prison or jail?


  1. …because the location was too far away?


  1. …because you haven’t found a medical care provider that spoke your language?


  1. …because you’ve had trouble getting transportation?


  1. …because you forgot?


  1. …because of some other reason(s)?


  1. If yes, please tell me the other reason(s) that you have not gone to get tested for tuberculosis.

____________________________


  1. Of all the reasons you just gave, what is the most important one? ___ (Enter only one response a-r)


(If the participant did not test for tuberculosis, go to questions for next referral)


  1. Did you receive a positive result for TB? (Choose one)


  1. Did you receive treatment for tuberculosis? (Choose one)


Interviewer: I’m going to read you a list of possible reasons people may not receive treatment for TB.


  1. Please tell me whether or not each reason applies to you. Is one of the reasons… (Only ask the questions in this section if participant indicates not receiving treatment for TB.) (Choose one)

  1. …because you have not filled your prescription yet?



  1. …because your medical care provider said you do not need treatment?



  1. …because you have problems paying for or getting insurance or coverage for treatment?

  1. …because you don’t think you need treatment?


  1. …because you think treatment would make you feel sick or harm you?


  1. …because treatment caused side effects in the past?


  1. …because you did not receive treatment for some other reason?


  1. Please tell me the other reason that you did not receive treatment?

__________________

  1. Of all the reasons you just gave, what is the most important one? ___ (Enter only one response a-h)


(If the participant did not receive treatment for tuberculosis, go to questions for next referral)


If referred to an “Other HIV Prevention Service”:


  1. You were referred to [SERVICE] Recpommended services include basic education continuation and completion services, employment services, housing services, insurance navigation and enrollment services, mental health counseling and services, sex education, including HIV education, substance abuse treatment and services, transportation services, or some other service)]. Did you talk to a professional about [SERVICE]? (Choose one)

(Repeat question above for each referral made to an “Other HIV Prevention Service”)


Shape1 End of Interview


Interviewer: This concludes the interview, thank you so much for your time. Someone will be in touch with you to conduct the next interview.




Reason:


Interviewer comments: Please note anything unusual about this interview. Tthis could be anything important shared by the client that could help us understand their responses, any device glitches, environmental/background factors at time of interview that may have affected client responses, etc. ____________________________________________________________________

_________________________________________________________________________________________________________

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