Study Drug Adherence Visit Month Screening ID: Participant ID: Visit Date: Site Screening Number Site Study Couple I/P Chk dd mm yy Study Drug Adherence These are interviewer-administered questions and should be read aloud directly as written. 1 When was the last time you took pills? dd mm yyyy 2 During the last month, did you take the tablet every yes no If yes, go to item 3. day? 2a How many days did you miss to take a study tablet? What is the most number of days in a row that you did 2b not take a study tablet? Very poor poor fair good Very Excellent 3 good Please tell me how well you have taken your study tablets as directed since the last visit. None of the A little Some A Most All of the 4 time of the of the good of the time time time bit of time the time In general, how do you take your study tablets? 5 During the past month, what has helped you to remember to take your tablets? Mark all that apply. Nothing Alarm Pill Study partner/family members Associates it with box activity Other, specify 6 During the past month, what caused you to not take your tablets? NA OR Mark all that apply Forgot alcohol use Change in routine prefer to take just before or after sex Illness Not having lost tablets missed a and sex had no tablets Do not have Traveled Confidentiality/stigma shared tablets with food someone else Tablet stolen thought tablets caused side Others effects 7 Did you decide to have sex because you did take your not not Yes No Missed no tablet study tablets that day? 8 For a variety of reasons, other persons may want to use your Yes No Not sure If no, end of study medication. Do you think that someone other than you form. has used any of your study tablets? a Do you think your study partner has used any of your tablets? Yes No Not sure b Do you someone else has used any of your study tablets? Yes No Not sure If no or not sure, go to item 8c bi Who? Don’t know c Estimate how many tablets were used by someone other than Don’t know you: Completed by: (initials/date) _________________________________________
Study Drug Adherence Visit Month Screening ID: Site Screening Number Participant ID: Site Study Couple I/P Chk Visit Date: dd mm yy Study Drug Adherence These are interviewer-administered questions and should be read aloud directly as written. 1 When was the last time you took pills? dd mm yyyy 2 During the last month, did you take the tablet every day? yes no If yes, go to item 3. 2a How many days did you miss to take a study tablet? 2b What is the most number of days in a row that you did not take a study tablet? 3 Please tell me how well you have taken your study tablets as directed since the last visit. Very poor poor fair good Very good Excellent 4 In general, how do you take your study tablets? None of the time A little of the time Some of the time A good bit of the time Most of the time All of the time 5 During the past month, what has helped you to remember to take your tablets? Mark all that apply. Nothing Alarm Pill box Study partner/family members Associates it with activity Other, specify 6 During the past month, what caused you to not take your tablets? Mark all that apply OR NA Forgot alcohol use Change in routine prefer to take just before or after sex Illness Not having sex lost tablets missed a and had no tablets Do not have food Traveled Confidentiality/stigma shared tablets with someone else Tablet stolen thought tablets caused side effects Others 7 Did you decide not to have sex because you did not take your study tablets that day? Yes No Missed no tablet 8 For a variety of reasons, other persons may want to use your study medication. Do you think that someone other than you has used any of your study tablets? Yes No Not sure If no, end of form. a Do you think your study partner has used any of your tablets? Yes No Not sure b Do you someone else has used any of your study tablets? Yes No Not sure If no or not sure, go to item 8c bi Who? Don’t know c Estimate how many tablets were used by someone other than you: Don’t know Completed by: (initials/date) _________________________________________
CRF2_Drug_Adherence.docx