Form 1 ELE-Participant eligibility - billingual

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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: NIH,
Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN:
PRA (0925-0584). Do not return the completed form to this address.

OMB#: 0925-0584
Exp. xx/xx/xxxx

DRAFT HCHS/SOL Visit 2 Eligibility Checklist
FORM CODE: ELE
VERSION: 1, 1/14/2014

ID NUMBER:

Contact
Occasion

0

2

SEQ #

0

1

ADMINISTRATIVE INFORMATION

/

0a. Completion Date (mm/dd/yyyy):

/

0b.

Staff ID:

Instructions: This individual eligibility screening form must be completed before the participant can be scheduled for
their Baseline Examination.
Introductory Script: Hello, may I speak to (name of eligible HH resident, recruited or being recruited). My name is __
and I would like to schedule your second visit at the HCHS/SOL exam center. Before we find a time that is convenient
for you, I would like to verify some details for my records to help us prepare for your visit.
Introducción: Hola, puedo hablar con (name of eligible HH resident, recruited or being recruited). Mi nombre es
________ y quisiera hacer una cita para su segunda visita al centro de HCHS/SOL. Antes de discutir una fecha
conveniente para usted me gustaría verificar algunos detalles suyos para ayudarnos a preparar su visita.
Eligibility Screening Status for Individual
Since I will not be the only person talking with you during your clinic visit, I would like to note your language of
preference for other staff for our use. (Como yo no soy la única persona que le va a hablar durante su visita al
centro, me gustaría anotar que idioma prefiere)

1. Do you prefer to communicate in Spanish or English?
(¿Prefiere comunicarse en español o en inglés?)
Neither language/ en ninguno de los dos (0) Ineligible 
Spanish/Español (1)
English/Inglés (2)

2. Do you have any plans to move away from this area in the next 6 months (more than 100 miles at San
Diego and Chicago, or more than 250 miles at Bronx and Miami)?
(¿Tiene usted planes de mudarse de esta zona en los próximos 6 meses?)
No (0)

Yes/Sí (1) Ineligible

NOTE TO STAFF: If communication in Spanish/English is considered too difficult, then administratively
exclude person being screened at this point and consider them ineligible. Otherwise, continue.
Do you have any questions about your participation in HCHS/SOL? Can we schedule your exam at the ____ now?
(¿Tiene usted alguna pregunta sobre su participación en HCHS/SOL? ¿Podemos programar una visita para el
examen ahora?)

3. Individual Participation Status:

4a. Appointment Date (mm/dd/yyyy):

ELE-Participant Eligiblity_1-14-2014-Eng-Sp.doc

Refuses to participate (1)
Unable to contact, status unknown (2)
Ineligible (3) Ineligible closing script
Agrees to participate (4) Eligible closing script

/

/

4b. Time:

:

(24hr.)

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