BCFS00240 Test Site [Screening Form] -

Screening Form

Please complete the screening form below and our team will be in touch. Thank you!

Are you at least 18 years old?

Yes

What state/territory do you live in?

Do you identify as Hispanic, Latino, Afro-Latino, or Spanish origin?

Yes

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What category best describes you?

American Indian or Alaska Native

Asian

Black or African American

Hispanic, Latino, or Spanish origin

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Are you able to read, speak, or write in English or Spanish?

Yes

Do you identify as a man, including trans man?

Yes

Have you ever been diagnosed with Mpox (Monkeypox)?

Yes

Have you received at least one round of vaccination against Mpox (Monkeypox)?

Yes

Are you currently in a sexual relationship with at least one man?

Yes

Since this study is for couples, is there one man—including a trans man—with whom you are having an ongoing sexual relationship for at least three months that you think would be willing to join the study with you?

Yes

Now, we will ask a few questions about this man. To the best of your knowledge, does this man self-identify as Hispanic, Latino, Afro-Latino or Spanish origin?

Yes

What state/territory does this man live in?

How long has your sexual relationship with this man been going on?

Less than 1 month

1-2 months

3-6 months

7-12 months

1 yr+

In the past 3 months, how many total times have you had penetrative sex with this man? (This includes anal/back hole sex or vaginal/front hole sex.)

Of these instances, how many times did you have anal/back hole and/or vaginal/front hole sex without using a condom?

In the past three months, have you had any sexual relationships with anyone (of any gender) other than the partner asked about in the questions you just answered?

Yes

In the past 3 months, how many times have you engaged in penetrative sex with other individuals? (This includes anal/back hole sex or vaginal/front hole sex.). Again, this does not include sex with the partner you think might be willing to join the study with you.

Of these X times, how many times did you have anal/back hole and/or vaginal/front hole sex without using a condom?

What is your HIV status?

Not living with HIV/HIV-Negative

Living with HIV/HIV Positive

Don't know

Are you currently on Antiretroviral Therapy (ART) to treat HIV?

Yes

How are you supposed to (prescribed) take your HIV treatment?

Pills that I am supposed to take every day

HIV treatment Injections (Cabenuva)

Both daily HIV pills and injections (Lenacapavir/Sunlica)

In the last 30 days, how often did you take your daily HIV pills in the way you were supposed to?

Never

Rarely

Sometimes

Usually

Almost Always

Always

In the last 30 days, how good of a job did you do at taking your daily HIV pills in the way you were supposed to?

Very Poor

Poor

Fair

Good

Very good

Excellent

In the last 30 days, on how many days did you miss at least one dose of any of your daily HIV pills?

Thinking back over the past 30 days, rate your ability to take your daily HIV pills in the way you are supposed to.

Very Poor

Poor

Fair

Good

Very good

Excellent

How often are you supposed to get your injections for HIV treatment?

Monthly injections/Every four weeks

Bi-monthly injections/Every eight weeks

Semi-annual injections with daily pills/ Every six months

Thinking back over the past 6 months, rate your ability to get your HIV medication injections on time. If you have been on injectable HIV treatment for less than 6 months, think about the time you have been on them.

Very Poor

Poor

Fair

Good

Very good

Excellent

In the last 6 months, how often did you get your HIV medication injections on the schedule you were supposed to?

Never

Rarely

Sometimes

Usually

Almost Always

Always

In the last 6 months, how good of a job did you do at getting your HIV medication injections in the way you were supposed to?

Very Poor

Poor

Fair

Good

Very good

Excellent

In the last six months, have you ever been more than two weeks late in getting any of your HIV medication injections?

Yes, I have been more than two weeks late one time in the last 6 months

Yes, I have been more than two weeks late more than once in the last 6 months

No, I have not been more than two weeks late

Are you currently on PrEP (Pre-Exposure Prophylaxis)?

Yes

How are you supposed to take your PrEP?

Pills that you are supposed to take every day

Pills that you are supposed to take before and after having sex (also known as 2-1-1 or On-Demand PrEP)

Injections every two months (Cabotegravir/Apretude)

When did you receive your last HIV medication injection(s)? If not sure, please give it your best estimate.

In the last 30 days, how often did you take your daily PrEP pills in the way you were supposed to?

Never

Rarely

Sometimes

Usually

Almost Always

Always

In the last 30 days, how good of a job did you do at taking your daily PrEP pills in the way you were supposed to?

Very Poor

Poor

Fair

Good

Very good

Excellent

In the last 30 days, on how many days did you miss at least one dose of any of your daily PrEP pills?

Thinking back over the past 30 days, rate your ability to take your daily PrEP pills in the way you are supposed to.

Very Poor

Poor

Fair

Good

Very good

Excellent

In the last 30 days how often did you take your PrEP pills in the way you were supposed to (before and after sex)?

Never

Rarely

Sometimes

Usually

Almost Always

Always

In the last 30 days, how good of a job did you do at taking your PrEP pills in the way you were supposed to (before and after sex)?

Very Poor

Poor

Fair

Good

Very good

Excellent

In the last 30 days, on how many days did you miss at least one dose of your PrEP pills when you should have taken it based on your dosing schedule?

Thinking back over the past 30 days, rate your ability to take your PrEP pills in the way you are supposed to (before and after sex)?

Very Poor

Poor

Fair

Good

Very good

Excellent

When did you receive your last PrEP injection(s)? If not sure, please give it your best estimate.

Thinking back over the past 6 months, rate your ability to get PrEP injections on time. If you have been on injectable PrEP for less than 6 months, think about the time you have been on them.

Very Poor

Poor

Fair

Good

Very good

Excellent

In the last 6 months, how often did you get your PrEP injections on the schedule you were supposed to?

Never

Rarely

Sometimes

Usually

Almost Always

Always

In the last 6 months, how good of a job did you do at getting your PrEP injections in the way you were supposed to?

Very Poor

Poor

Fair

Good

Very good

Excellent

In the last six months, have you ever been more than two weeks late in getting any of your PrEP medication injections?

Yes, I have been more than two weeks late one time in the last 6 months

Yes, I have been more than two weeks late more than once in the last 6 months

No, I have not been more than two weeks late

Do you have access to internet access and a digital device (smart phone, computer, laptop, or tablet) that you can use to participate in this online research study?

Yes

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First Name

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Last Name

Phone Number

Email Address

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Screening Form

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