Page 1 of 6 SURVEY: PROJECT TECH

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1 SURVEY: PROJECT TECH Case managers: Thank you for working with us to administer the survey. Please read each question as it is written. Instructions for you are written in italics. Information that you should read to the client is in a regular font. Case managers: Please complete the following information about you and your site. What is the name of your organization? What is your name? Case managers: Please write the client ID. This can be whatever ID you use to identify the client (for example, the client's Ryan White number). This is being collected so that we can avoid duplication in the survey responses. Case managers: Please indicate the language that your client prefers to speak. English Spanish Another language (specify below) Case managers: Please read the informed consent document below to your client. Information to Consider Before Taking Part in this Research Study Involving Minimal Risk IRB Study # U9 We are asking you to take part in a research study called: Project TECH: Technology Experiences and Care for HIV The person who is in charge of this research study is Dr. Stephanie Marhefka. Other research staff may be involved and can act on behalf of the person in charge. As a case manager, I will be part of the research team. I will see if you want to participate in the study and if you agree, I will ask you 10 questions. Purpose of the study The purpose of this study is to find out about the extent to which people living with HIV in Florida can use and would like to use their own devices (such as computers or phones) to access technology-based interventions. Study Procedures: What will happen during this study? If you take part in this study, you will be asked to: Complete a brief survey that your Ryan White case manager will read aloud to you. This should take no more than 10 minutes. We will also ask you if you would like to be contacted about future stages of this research project. If you do agree to be contacted, we will ask you to provide contact information. Benefits You will receive no direct benefits for participation; however you may feel good that you are providing information that may help others living with HIV. Risks or Discomfort There are no physical risks associated with participation in the project. You may reveal sensitive information during assessment and, although it is unlikely, could experience feelings of distress when answering questions related to your HIV status and intervention preferences. Compensation There is no direct compensation for taking this assessment; however, you can provide contact information if you would like to enter into a raffle to win one of 500 $15 gift cards. Page 1 of 6

2 Privacy and Confidentiality We will keep your study records private and confidential. It is possible, although unlikely, that unauthorized individuals could gain access to your responses. Certain people may need to see your study records. By law, anyone who looks at your records must keep them completely confidential. The only people who will be allowed to see these records are: The research team. Certain government and university people who need to know more about the study. For example, individuals who provide oversight on this study may need to look at your records. This is done to make sure that we are doing the study in the right way. They also need to make sure that we are protecting your rights and your safety. Any agency of the federal, state, or local government that regulates this research. This includes the Department of Health and Human Services (DHHS) and the Office for Human Research Protection (OHRP). The Florida Department of Health Institutional Review Board (IRB) and its related staff, who have oversight responsibilities for this study The USF Institutional Review Board (IRB) and its related staff, who have oversight responsibilities for this study, staff in the USF Office of Research and Innovation, USF Division of Research Integrity and Compliance, and other USF offices who oversee this research. We may publish what we learn from this study. If we do, we will not include your name. We will not publish anything that would let people know who you are. Voluntary Participation / Withdrawal You should only take part in this study if you want to volunteer. You should not feel that there is any pressure to take part in the study. You are free to participate in this research or withdraw at any time. There will be no penalty or loss of benefits you are entitled to receive if you stop taking part in this study. Your decision to participate or not will not affect any care you receive related to living with HIV. Participation in Future Studies We will also ask you if you would like to provide contact information to participate in future studies. If you provide this information we will: 1) Link your contact information to your survey answers so we can connect the data you give us now to the data you might give us in the future 2) Store your contact information in an encrypted secure folder accessible only to select research staff. You can get the answers to your questions, concerns, or complaints If you have any questions, concerns or complaints about this study, or experience an adverse event, research-related injury or unanticipated problem, call Dr. Stephanie Marhefka at If you want to talk with someone independent of the research team for questions, concerns, or complaints about the research; questions about your rights; to obtain information; or to offer input, you can contact the Florida Department of Health Institutional Review Board. An Institutional Review Board is a group of people who review research to ensure participants are protected and the research is conducted in an ethical way. You can contact the IRB at: Case managers: Read the following question the client: Would you like to participate in this study? Case managers: Read the statement below to yourself and write your full name. This should be your name, not the client's name. Statement of Person Obtaining Informed Consent I have carefully explained to the subject the nature of the above research study. I hereby certify that to the best of my knowledge the subject providing verbal consent understands the nature, demands, risks, and benefits involved in participating in this study. Case managers: Go to the next page to start the study Page 2 of 6

3 SURVEY Case managers: Please ask your client the following questions and document the answers below. 1. What is your ZIP code? Case managers: If the client is homeless, enter the ZIP code in which they typically sleep. 2. How old are you (in years)? 3. The next question is about your race and ethnicity. Tell me yes or no for each one. Are you: Hispanic or Latino? Black or African American? White or Caucasian? Asian or Other Pacific Islander? Native American? 4. What is your gender? I have to ask everyone. Please say "" or "" for each item. Are you: Female? Male? Trans Male? Trans Female? Another gender? Write below*: 5. w I have a question about your sexual experience. Have you ever had sex with a man? Have you ever had sex with a woman? Page 3 of 6

4 6. w I am going to ask you about technology. Do you use any of the following? A desktop, laptop, netbook, or notebook computer A tablet computer like an ipad, Samsung Galaxy, or Windows Tablet A mobile phone or cellphone with text messaging Apps on your mobile phone or cellphone The Internet on your mobile phone or cellphone Another type of computer Write below*: 7. Do you ever use the Internet or At home? Outside of your home? I m homeless 8. Do you or any member of your household access the Internet at home using the following types of connections? Please say "" or "" for each item. A subscription to an Internet service? A mobile phone or cellphone? Dial up service? Internet service like DSL, cable modem, fiber-optic, or satellite Internet? (Case managers: If the client does not know but states a company name, such as "Verizon" write below.*) I don t know I m homeless Page 4 of 6

5 9. Do you ever use the Internet to do any of the following activities? Send or receive ? Do an online search? Use social networking sites like Facebook, Myspace, Instagram, or Twitter? Video-chat like with Skype, Oovo, Facetime, or another program? Get information about HIV? Communicate with other people who are living with HIV? Finding partners or companions online through sites like POZ, Personals, Match.com, Grindr, OkCupid, OurTime, or Tinder? 10. Earlier I asked you about the devices you have used in the past, now I will ask you about devices you would ever be willing to use. Would you ever be willing to use the following devices to access information about HIV? A desktop, laptop, netbook, or notebook computer A tablet computer like an ipad, Samsung Galaxy, or Windows Tablet A mobile phone or cellphone with text messaging Apps on your mobile phone/cellphone The Internet on your mobile phone/cellphone Another type of device or computer Specify by writing on the line*: You have the opportunity to be entered into a raffle to receive one of 500 $15 gift cards. To be entered into the raffle we need your contact information. You can also indicate if you would like to be contacted for future phases of the research. If you take part in future phases of the research you will be compensated for your time. Please answer each of the following questions. You will ONLY be contacted for the reasons you tell me. Would you like to be entered into the raffle? Can we contact you to participate in future phases of this research? Next Page Page 5 of 6

6 Case managers: If the client did not answer to either question above, please skip the remaining questions. w please tell me about how to contact you. Name Mailing address City State Zip code Phone number address Sometimes people move or change their phone number. In case we cannot reach you at the number you provided, please provide the contact information of someone else who will know how to reach you. Many people decide to give their case manager's name and phone number. Name Relationship to you Phone number address There are 3 options for receiving the gift cards. You will receive your gift card soonest if you choose text or . Mailed gift cards may take up to 2 months to receive. Please indicate which option you would prefer checking the box Choose only ONE option: , Text, OR Mail. Target - sent via Walmart - sent via Amazon - sent via Target - mailed to an address you will provide Walmart - mailed to an address you will provide Target - sent via text message to your phone Case managers: Please ask your client to confirm the following information. This is being requested because the client indicated they would like to receive their gift card via if they are selected in the raffle. Name address Case managers: Please ask your client to confirm the following information. This is being requested because the client indicated they would like to receive their gift card via mail if they are selected in the raffle. Name Address City State Zip code Case managers: Please ask your client to confirm the following information. This is being requested because the client indicated they would like to receive their gift card via text messaging if they are selected in the raffle. Phone number Page 6 of 6