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National HIV Behavioral Surveillance System: Core Questionnaire
N1 – N3f FOR NHBS-IDU AND NHBS-HET ONLY
IF RESPONDENT IS A NOT A SEED (INT12=0), ASK N1
N1.
Which of the following describes how you know the person who gave you this coupon? You
can choose more than one answer. [READ CHOICES. CHECK ALL THAT APPLY.]
A friend ……...................................................................
1
A sex partner, girlfriend/boyfriend, husband or wife......
2
A relative or family member…………………...............
3
A co-worker…………………………………………….
4
A person you use drugs with…………………...............
5
A person you buy drugs from…………………..............
6
A person you share needles with………………….........
An acquaintance (that is, a person you know,
7
but do not consider friend)……………….………...
You don’t know the person/just met
8
them (a stranger) ………………………………….
Refused to answer………………………………………
9
77
FOR NHBS-IDU, ASK N2-N2g
FOR NHBS-HET, ASK N3-N3f
N2.
How many people in [insert project area] do you know personally who inject?
[Refused= 777, Don’t Know= 999] ___ ___ ___
NHBS Data Collection Instrument
July 2007
If 0, 777, or 999,
skip to Say Box
before Q1
14
Core Questionnaire
N2a.
Of the ________[insert number from N2] people who live in [insert project area] and who
you personally know who inject, how many have you seen at least once in the past 30 days?
[Refused= 777, Don’t Know= 999] ___ ___ ___
N2b.
If 0, 777, or 999,
skip to Say Box
before Q1.
Of the ________[insert number from N2a] people who inject that you have seen in the past
30 days, how many are male?
[Refused= 777, Don’t Know= 999] ___ ___ ___
N2c.
Of the ________[insert number from N2a] people who inject that you have seen in the past
30 days, how many are female?
[Refused= 777, Don’t Know= 999] ___ ___ ___
SAY: What is the race or ethnic background of the __ [insert number from N2a] people who
inject that you have seen in the past 30 days? That is, how many were white, black, Hispanic,
or another race?
N2d.
White [Refused= 777, Don’t Know= 999]
___ ___ ___
N2e.
Black [Refused= 777, Don’t Know= 999]
___ ___ ___
N2f.
Hispanic [Refused= 777, Don’t Know= 999]
___ ___ ___
N2g.
Another Race [Refused= 777, Don’t Know= 999]
before Q1
___ ___ ___
NHBS Data Collection Instrument
July 2007
For NHBS-IDU,
skip to Say Box
before Q1.
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Core Questionnaire
FOR NHBS-HET
N3.
Please tell me how many friends, relatives or people you are close to who are at least 18 years
of age, live in [project area], and you have seen in the past 30 days. [GIVE RESPONDENT
NETWORK FLASHCARD]
If 0, 777, or 999,
skip to Say Box
before Q1.
[Refused= 777, Don’t Know= 999] ___ ___ ___
N3a.
Of the ________[insert number from N3] people that you have seen in the past 30 days, how
many are male?
[Refused= 777, Don’t Know= 999] ___ ___ ___
N3b.
Of the ________[insert number from N3] people that you have seen in the past 30 days, how
many are female?
[Refused= 777, Don’t Know= 999] ___ ___ ___
SAY: What is the race or ethnic background of the __ [insert number from N3] people that
you have seen in the past 30 days? That is, how many were white, black, Hispanic, or another
race?
N3c.
White [Refused= 777, Don’t Know= 999]
___ ___ ___
N3d.
Black [Refused= 777, Don’t Know= 999]
___ ___ ___
N3e.
Hispanic [Refused= 777, Don’t Know= 999]
___ ___ ___
N3f.
Another Race [Refused= 777, Don’t Know= 999]
___ ___ ___
NHBS Data Collection Instrument
July 2007
16
Core Questionnaire
Next, I'd like to ask you some questions about where you live. Please remember
your answers will be kept private.
1.
1a.
In the past 12 months, have you been homeless at any time? By homeless, I mean you were
living on the street, in a shelter, a Single Room Occupancy hotel (SRO), temporarily staying
with friends or relatives, or living in a car?
No………………….……………………………
0
Yes………………………………………………
1
Refused to answer………………………………
7
Don't know……………..……………………….
9
Skip to Q2 for NHBS-MSM and
NHBS-IDU; Skip to Q3 for NHBS-HET
Skip to Q2 for NHBS-MSM and
NHBS-IDU; Skip to Q3 for NHBS-HET
Are you currently homeless?
No………………….……………….…………..
0
Yes….……………………………….…….........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
Skip to Q3 for NHBS-HET
FOR NHBS-MSM AND NHBS-IDU, ASK Q2
2.
3.
What zip code do you live in?
[Refused = 77777, Don't know = 99999]
__ __ __ __ __
Next, I would like to ask you some questions about your background. What country were you
born in? [DO NOT read choices. Check only one.]
United States….………………….………….….
1
Mexico….………………….………….………..
2
Puerto Rico….………………….………….……
3
Cuba…….………………….………….………..
4
NHBS Data Collection Instrument
July 2007
Skip to Q4 for NHBS-IDU and NHBSHET; Skip to Q5 for NHBS-MSM
Skip to Q4 for NHBS-IDU and NHBSHET if CITY=Puerto Rico; Skip to Q5
for NHBS-MSM if CITY=Puerto Rico
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Core Questionnaire
3a.
Other (Specify_________________)………...…
5
Refused to answer………………………….…...
77
Don't know…….………………………….…...
99
Skip to Q4 for NHBS-IDU and NHBS-HET;
Skip to Q5 for NHBS-MSM
What year did you first come to live in the United States?
[7777 = Refused, 9999 = Don't know]
__ __ __ __
(Y
Y
Y
Y)
FOR NHBS-IDU AND NHBS-HET, ASK Q4-Q4a
4.
What is your current marital status? [READ CHOICES. CHECK ONLY ONE.]
Married………………………………………….
1
Living together as married……………………...
2
Separated…….……….…………………..……..
3
Divorced…….…….…………………..………..
4
Widowed….………..…………………………...
5
Never married………..………………………….
6
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
If Q4= 2, ask Q4a. Otherwise, skip to Q5.
4a.
Is your formal marital status separated, divorced, widowed, or never married?
Separated…….……….…………………..……..
1
Divorced…….…….…………………..………..
2
Widowed….………..…………………………...
3
Never married………..………………………….
4
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
NHBS Data Collection Instrument
July 2007
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Core Questionnaire
5.
6.
What is the highest level of education you completed?
[DO NOT read choices. Check only one.]
Never attended school….………………………….
00
Grades 1 through 8….…………………...………..
01
Grades 9 through 11..…………………….…….….
02
Grades 12 or GED...….……..…..…………………
Some college, Associate’s Degree, or
03
Technical Degree……………………………….
04
Bachelor’s Degree..………….…………….………
05
Any post graduate studies ………….…………….
06
Refused to answer………………..………………..
77
Don't know……..………………..………………..
99
What best describes your employment status? Are you:
[READ CHOICES. CHECK ONLY ONE.]
Employed full-time………………….………….
01
Employed part-time…………………………….
02
A homemaker….……….…………………...…..
03
A full-time student…….…….…………………
04
Retired….………..……………………………...
05
Disabled for work….………..………………….
06
Unemployed………..…………………………...
07
Other………..…………………………..............
08
Refused to answer………………………..……..
77
Don't know.……………..………………..........
99
NHBS Data Collection Instrument
July 2007
19
Core Questionnaire
For Respondents who are not currently homeless (Q1=0 OR Q1a=0):
Say: Next I'd like to ask you some questions about your household income. By "household
income," I mean the total amount of money earned and shared by all people living in your
household.
For Respondents who are currently homeless (Q1a=1):
Say: Next I'd like to ask you some questions about your income. By "income," I mean the
total amount of money you earn or receive. This includes money other people share with
you.
7.
What was your [insert household income if Q1=0 OR Q1a=0; insert income if Q1a=1] last year
from all sources before taxes?
GIVE RESPONDENT FLASHCARD A. DO NOT read choices.
Please take a look at this card and tell me the letter that best corresponds to your monthly or yearly
income.
Monthly Income
7a.
Yearly Income
a. 0 to $417……………...a. 0 to $4,999……………….
00
b. $418 to $833………… b. $5,000 to $9,999………..
01
c. $834 to $1250…………c. $10,000 to $14,999...……
02
d. $1251 to $1667.…….... d. $15,000 to $19,999.…….
03
e. $1668 to $2500………..e. $20,000 to $29,999……..
04
f. $2501 to $3333……….. f. $30,000 to $39,999……..
05
g. $3334 to $4167………. g. $40,000 to $49,999……..
06
h. $4168 to $6250………. h. $50,000 to $74,999……..
07
i. $6251 or more………... i. $75,000 or more…………
08
Refused to answer………. ……………………………….
77
Don't know……..……………………………………….....
99
Skip to Q8
Including yourself, how many people depended on this income?
[MUST BE AT LEAST 1.]
[Refused = 77, Don't know = 99]
NHBS Data Collection Instrument
July 2007
___ ___
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Core Questionnaire
8.
8a.
9.
9a.
Do you currently have health insurance or coverage? This includes Medicaid or Medicare.
No………………….……………………………
0
Yes……………………………………………...
1
Refused to answer………………………………
7
Don't know……………..……………………...
9
Skip to Q9
Skip to Q9
What kind of health insurance or coverage do you currently have?
[DO NOT read choices. Check all that apply.]
Private health insurance or HMO………………
01
Medicaid….……….…………………..………..
02
Medicare…….…….…………………..………..
03
TRICARE (CHAMPUS)….………..…………..
04
Veterans Administration coverage………..……
05
Some other insurance……………….…………..
(Specify______________________________)
06
Refused to answer………………………………
77
Don't know……………..……………………..
99
Have you seen a doctor, nurse, or other health care provider in the past 12 months?
No………………….……………………………
0
Yes……………………………………………...
1
Refused to answer………………………………
7
Don't know……………..……………………...
9
Skip to Q10
Skip to Q10
At any of those times you were seen, were you offered an HIV test? An HIV test checks whether
someone has the virus that causes AIDS.
No………………….……………………………
0
Yes……………………………………………...
1
Refused to answer………………………………
7
Don't know……………..……………………...
9
NHBS Data Collection Instrument
July 2007
21
Core Questionnaire
10.
Do you consider of yourself to be: [READ CHOICES. CHECK ONLY ONE.]
Heterosexual or "Straight"…………….……......
1
Homosexual, Gay, or Lesbian………………….
2
Bisexual………………………………………..
3
Refused to answer…………………..………….
7
Don’t know................……………………….….
9
Skip to Say Box before Q11
Skip to Say Box before Q11
If Respondent is male (ES9=1), ask Q10a;
Otherwise, skip to Say Box before Q11.
10a.
Have you ever told anyone that you are attracted to or have sex with men?
10b.
No………………….……………….…………..
0
Yes….……………………………….…….........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
Skip to Say Box before Q11
I'm going to read you a list of people you may have told. Please tell me which ones apply. Have
you told: [READ CHOICES, CHECK ALL THAT APPLY.]
No
Yes
Refused Don’t
to answer know
1. Gay, lesbian, or bisexual friends ……... ……………
0…
1…..
7….
9
2. Friends who are not gay, lesbian, or bisexual………
0…
1…..
7….
9
3. Family members……………………………………
0…
1…..
7….
9
4. Spouse or partner…………………………………..
0…
1…..
7….
9
5. Health care provider…….………………………….
0…
1…..
7….
9
FOR NHBS-IDU AND NHBS-HET: ASK 10b.4
NHBS Data Collection Instrument
July 2007
22
Core Questionnaire
SEXUAL BEHAVIOR
SAY: Next, I'm going to ask you some questions about having sex. Please remember your
answers will be kept private. GIVE RESPONDENT FLASHCARD B.1
For these questions, "having sex" means oral, vaginal, or anal sex. Oral sex means mouth on the
vagina or penis; vaginal sex means penis in the vagina; and anal sex means penis in the anus
(butt). I need to ask you all the questions, even if some may not apply to your situation.
Interviewer: Use your discretion in using slang terms for the following sexual
behavior questions.
INTERVIEWER INSTRUCTIONS: Refer to response to Gender Question (ES9).
Male
Female
FOR NHBS-MSM AND NHBS-IDU, GO TO Q11
FOR NHBS-HET, GO TO Q12
FOR NHBS-IDU, GO TO Q68
FOR NHBS-HET, GO TO Q69
FOR MALE RESPONDENTS ONLY
Female Sex Partners (Male respondent)
11.
12.
Have you ever had vaginal or anal sex with a woman?
No………………….……………………………
0
Yes……………………………………………...
1
Refused to answer………………………………
7
Don't know……………..…………………….....
9
Skip to Say Box before Q39
How old were you the first time you had vaginal or anal sex with a woman?
[77 = Refused, 99 = Don't know]
13.
Skip to Say Box before Q39
__ __
In the past 12 months, with how many different women have you had oral, vaginal, or anal
sex?
___ ___ ____ ____
[Refused = 7777, Don't know = 9999]
NHBS Data Collection Instrument
July 2007
If 0, 7777, or 9999, skip to Say Box before Q39
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Core Questionnaire
Skip Pattern for # of Female Sexual Partners:
If Q13 =1, ask Q14a.
Otherwise ask Q14.
FOR MULTIPLE FEMALE SEX PARTNERS
[Read Say Box and Questions in this column]
SAY: Now I'm going to ask you to describe these sex
partners as either main, casual, or exchange partners.
FOR ONE FEMALE SEX PARTNER
[Read Say Box and Question in this column]
SAY: Now I'm going to ask you to describe this sex
partner as either a main, casual, or exchange partner.
[GIVE RESPONDENT FLASHCARD C]
[GIVE RESPONDENT FLASHCARD C]
By “main partner” I mean a woman you have sex with
and who you feel committed to above anyone else. This
is a partner you would call your girlfriend, wife,
significant other, or life partner. By “casual partner” I
mean a woman you have sex with but do not feel
committed to or don't know very well. And by "exchange
partner" I mean a woman you have sex with in exchange
for things like money or drugs.
By “main partner” I mean a woman you have sex with and
who you feel committed to above anyone else. This is a
partner you would call your girlfriend, wife, significant
other, or life partner. By “casual partner” I mean a
woman you have sex with but do not feel committed to or
don't know very well. And by "exchange partner" I mean a
woman you have sex with in exchange for things like
money or drugs.
Refused = 7777, Don't know = 9999
Question
Response
14. Of the _____ [insert
number from Q13] women
you’ve had oral, vaginal, or
anal sex with in the past 12
months, how many of them
were main partners?
15. How many were casual
partners?
16. How many were
exchange partners?
[_____]
[_____]
Skip Pattern
If Q14=Q13,
skip to Say Box
before Q17a.
If Q14+Q15
=Q13, skip to
Say Box before
Q17a.
Question
14a. Was this woman a main partner, a casual partner, or
an exchange partner?
Main partner……
1
Skip to Say Box before Q17a
Casual partner…..
2
Skip to Say Box before Q18a
Exchange partner..
3
Skip to Say Box before Q19a
Refused to answer..
7
Don't know……….
9
Skip to Say Box before Q20
[_____]
Skip Pattern for Multiple Female Sex Partners:
If Q14 is not equal to 0, 7777, or 9999, go to Say Box below.
Otherwise, if Q15 is not equal to 0, 7777, or 9999, go to Say Box before Q18a.
Otherwise, if Q16 is not equal to 0, 7777, or 9999, go to Say Box before Q19a.
NHBS Data Collection Instrument
July 2007
24
Core Questionnaire
MAIN PARTNERS
MULTIPLE MAIN FEMALE PARTNERS
[Read questions in this column]
Refused = 7777, Don't know = 9999
SAY: Now I'm going to ask you about the _______ [insert
number from Q14] female main sex partners you had in the
past 12 months. Remember, a main sex partner is someone
you feel committed to above anyone else.
Question
Response
Skip Pattern
ONE MAIN FEMALE PARTNER
[Read questions in this column]
No = 0, Yes = 1, Refused = 7, Don't know = 9
SAY: Now I'm going to ask you about the female main sex
partner you had in the past 12 months. Remember, a main
sex partner is someone you feel committed to above
anyone else.
Question
Response
Skip Pattern
17a. Of your ______ [insert
number from Q14] female
main partners in the past 12
months, with how many did
you have vaginal sex?
17a. In the past 12
months, did you have
vaginal sex with this
woman?
17b. In the past 12 months,
with how many of these
______ [insert number from
Q17a] women did you have
vaginal sex without using a
condom?
17c. Of your ______ [insert
number from Q14] female
main partners in the past 12
months, with how many did
you have anal sex?
17d. In the past 12 months,
with how many of these
______ [insert number from
Q17c] women did you have
anal sex without using a
condom?
[_____]
If 0, 7777, or
9999, skip to
Q17c.
17b. In the past 12
months, did you have
vaginal sex with her
without using a
condom?
[_____]
[_____]
[_____]
NHBS Data Collection Instrument
July 2007
If 0, 7777, or
9999, skip to
Q17e.
17c. In the past 12
months, did you have
anal sex with this
woman?
17d. In the past 12
months, did you have
anal sex with her
without using a
condom?
If 0, 7, or 9, skip to
Q17c.
[_____]
[_____]
If 0, 7, or 9, skip to
Q17e.
[_____]
[_____]
25
Core Questionnaire
MAIN PARTNERS (con't)
MULTIPLE MAIN FEMALE PARTNERS
[Read questions in this column]
Refused = 7777, Don't know = 9999
Question
Response Skip Pattern
17e. Of your ____ [insert
[_____]
number from Q14] female
If 0, 7777, or
9999 AND
main partners, with how
Q15
is not
many did you have sex for
equal
to 0,
the first time in the past 12
skip
to
Say
months?
ONE MAIN FEMALE PARTNER
[Read questions in this column]
No = 0, Yes = 1, Refused = 7, Don't know = 9
Question
Response
Skip Pattern
17e. Did you have
[_____]
sex with this
If 0, 7, or 9, AND
Q14a=1, skip to
woman for the first
Q20. Otherwise, if
time in the past 12
0, 7, or 9, AND
months?
17f. With how many of
these ____ [insert number
from Q17e] women did
you discuss BOTH your
HIV status and their HIV
status before you had sex
for the first time?
17f. Did you
discuss BOTH your
HIV status and her
HIV status before
you had sex for the
first time?
Q15 are not equal
to 0, skip to Say
Box before Q18a.
Box before
Q18a.
[_____]
[_____]
If Q14a=1, skip
to Q20.
Skip Pattern for Multiple Female Sex Partners:
If Q14=Q13, Skip to Q20.
Otherwise, if Q15 is not equal to 0, 7777, or 9999, go to Say Box before Q18a.
Otherwise, if Q16 is not equal to 0, 7777, or 9999, go to Say Box before Q19a.
NHBS Data Collection Instrument
July 2007
26
Core Questionnaire
CASUAL PARTNERS
MULTIPLE CASUAL FEMALE PARTNERS
[Read questions in this column]
Refused = 7777, Don't know = 9999
SAY: Now I'm going to ask you about the _______ [insert
number from Q15] female casual sex partners you had in
the past 12 months. Remember, a casual sex partner is
someone you do not feel committed to or don't know very
well.
Question
Response
Skip Pattern
ONE CASUAL FEMALE PARTNER
[Read questions in this column]
No = 0, Yes = 1, Refused = 7, Don't know = 9
SAY: Now I'm going to ask you about the female casual
sex partner you had in the past 12 months. Remember, a
casual sex partner is someone you do not feel committed
to or don't know very well.
18a. Of your ______ [insert
number from Q15] female
casual partners in the past 12
months, with how many did
you have vaginal sex?
18a. In the past 12
months, did you
have vaginal sex
with this woman?
18b. In the past 12 months,
with how many of these
______ [insert number from
Q18a] women did you have
vaginal sex without using a
condom?
18c. Of your ______ [insert
number from Q15] female
causal partners in the past 12
months, with how many did
you have anal sex?
18d. In the past 12 months,
with how many of these
______ [insert number from
Q18c] women did you have
anal sex without using a
condom?
18e. Of your ____ [insert
number from Q15] female
casual partners, with how
many did you have sex for the
first time in the past 12
months?
18f. With how many of these
____ [insert number from
Q18e] women did you
discuss BOTH your HIV
status and their HIV status
before you had sex for the
first time?
[_____]
If 0, 7777, or
9999, skip to
Q18c.
18b. In the past 12
months, did you
have vaginal sex
with her without
using a condom?
[_____]
[_____]
If 0, 7777, or
9999, skip to
Q18e.
[_____]
NHBS Data Collection Instrument
July 2007
18c. In the past 12
months, did you
have anal sex with
this woman?
18d. In the past 12
months did you
have anal sex with
her without using a
condom?
[_____]
[_____]
Question
If 0, 7777, or
9999 AND
Q16 is not equal
to 0, skip to Say
Box before
Q19a.
18e. Did you have
sex with this
woman for the first
time in the past 12
months?
18f. Did you
discuss BOTH your
HIV status and her
HIV status before
you had sex for the
first time?
Response
Skip Pattern
If 0, 7, or 9, skip to
Q18c
[_____]
[_____]
If 0, 7, or 9, skip
to Q18e.
[_____]
[_____]
[_____]
If 0, 7, or 9, AND
Q14a=2, skip to Q20.
Otherwise, if 0, 7, or 9
AND Q16 are not
equal to 0, skip to Say
Box before Q19a.
If Q13a=2, skip to Q19.
[_____]
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Core Questionnaire
Skip Pattern for Multiple Female Sex Partners:
If Q14 + Q15=Q13, go to Q20.
Otherwise, go to Say Box before Q19a.
EXCHANGE PARTNERS
MULTIPLE EXCHANGE FEMALE PARTNERS
[Read questions in this column]
Refused = 7777, Don't know = 9999
SAY: Now I'm going to ask you about the _______ [insert
number from Q16] female exchange sex partners you had in
the past 12 months. Remember, an exchange partner is
someone you have sex with in exchange for things like
money or drugs.
Question
Response
Skip Pattern
ONE EXCHANGE FEMALE PARTNER
[Read questions in this column]
No = 0, Yes = 1, Refused = 7, Don't know = 9
SAY: Now I'm going to ask you about the female
exchange sex partner you had in the past 12 months.
Remember, an exchange partner is someone you have
sex with in exchange for things like money or drugs.
19a. Of your ______ [insert
number from Q16] female
exchange partners in the past
12 months, with how many
did you have vaginal sex?
19b. In the past 12 months
with how many of these
______ [insert number from
Q19a] women did you have
sex without using a condom?
19a. In the past 12
months, did you
have vaginal sex
with this woman?
19c. Of your ______ [insert
number from Q16] female
exchange partners in the past
12 months, with how many
did you have anal sex?
19d. In the past 12 months,
with how many of these
______ [insert number from
Q19c] women did you have
anal sex without using a
condom?
[_____]
If 0, 7777, or
999, skip to
Q19c.
19b. In the past 12
months did you
have vaginal sex
with her without
using a condom?
[_____]
[_____]
[_____]
NHBS Data Collection Instrument
July 2007
Question
If 0, 7777, or
9999, skip to
Q19e.
19c. In the past 12
months, did you
have anal sex with
this woman?
19d. In the past 12
months did you
have anal sex with
her without using a
condom?
Response
Skip Pattern
If 0, 7, or 9, skip to
Q19c.
[_____]
[_____]
If 0, 7, or 9, skip
to Q19e.
[_____]
[_____]
28
Core Questionnaire
EXCHANGE PARTNERS (con't)
MULTIPLE EXCHANGE FEMALE PARTNERS
[Read questions in this column]
Refused = 7777, Don't know = 9999
Skip Pattern
19e. Of your ______ [insert
number from Q16] female
exchange partners in the past
12 months, how many did
you give things like money or
drugs in exchange for sex?
19f. Of your ______ [insert
number from Q16] female
exchange partners in the past
12 months, how many gave
you things like money or
drugs in exchange for sex?
19g. Of your ____ [insert
number from Q16] female
exchange partners, with how
many did you have sex for the
first time in the past 12
months?
19h. With how many of these
____ [insert number from
Q19g] women did you
discuss BOTH your HIV
status and their HIV status
before you had sex for the
first time?
20.
Question
ONE EXCHANGE FEMALE PARTNER
[Read questions in this column]
No = 0, Yes = 1, Refused = 7, Don't know = 9
Response
[_____]
19f. In the past 12
months, did this woman
give you money, drugs,
or other things in
exchange for sex?
[_____]
[_____]
Skip Pattern
19e. In the past 12
months, did you give
this woman things like
money or drugs in
exchange for sex?
If 0, 7777,
or 9999,
skip to Q20.
[_____]
19g. Did you have sex
with this woman for the
first time in the past 12
months?
19h. Did you discuss
BOTH your HIV status
and her HIV status
before you had sex for
the first time?
Question
Response
[_____]
[_____]
[_____]
If 0, 7, or 9,
skip to Q20.
[_____]
Now I would like you to think about the last time you had sex with a woman. When was the last
time you had oral, vaginal, or anal sex with a woman? Just tell me the month and year.
[77/7777 = Refused, 99/9999 = Don't know]
__ __/ __ __ __ _
(M M / Y
Y
Y
Y)
Skip Pattern:
If Q14a= 3, go to Q22.
Otherwise, if Q13=1, go to Q23.
Otherwise, if Q13>1, ask Q21.
NHBS Data Collection Instrument
July 2007
29
Core Questionnaire
21.
22.
23.
24.
Was the woman you had sex with that last time a main partner, a casual partner, or an exchange
partner?
Main sex partner………......................................
1
Casual sex partner………....................................
2
Exchange sex partner………...............................
3
Refused to answer................................................
7
Don’t know………..............................................
9
Skip to Q23
Skip to Q23
When you had sex that last time, did you give her things in exchange for sex or did she give you
things in exchange for sex? [DO NOT read choices. Check only one.]
I gave her things in exchange for sex….……….
0
She gave me things in exchange for sex ………
1
Refused to answer…………………..…...……..
7
Don't know…………….…………………........
9
When you had sex that last time, did you have vaginal sex?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
Skip to Q28
Skip to Q28
During vaginal sex that last time, did you or your partner use a condom?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
NHBS Data Collection Instrument
July 2007
Skip to Q27
Skip to Q27
30
Core Questionnaire
24a.
25.
26.
27.
Did you or your partner use the condom the whole time?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
Did you or your partner use the condom to prevent pregnancy, to prevent infections like HIV or
other sexually transmitted diseases, to prevent both, or for some other reason?
Pregnancy ………………….…….….................
1
HIV/STDs…………………… ………………..
2
Both….…………………………………………
3
Other reason…………….…….....……………..
4
Refused to answer…………………..…….…….
7
Don't know……………..……………...…........
9
Skip to Q27
Skip to Q27
When you had vaginal sex that last time, were you or your partner using anything else besides
condoms to prevent pregnancy, such as birth control pills, pulling out/withdrawal, not having sex
at certain times/rhythm, or other birth control methods?
No………………….………….………………...
0
Yes………………………………..…………......
1
Refused to answer…………………………..…..
7
Don't know……………..………….………......
9
Skip to Q28
When you had vaginal sex that last time, were you or your partner using anything to prevent
pregnancy such as birth control pills, having a vasectomy, having tubes tied, pulling
out/withdrawal, not having sex at certain times/rhythm, or other birth control methods?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
NHBS Data Collection Instrument
July 2007
31
Core Questionnaire
28.
29.
29a.
When you had sex that last time, did you have anal sex?
No……………………………………………….
0
Yes……………………………………..………..
1
Refused to answer………………….…………..
7
Don't know…….…………………………........
9
Skip to Confirmation
Message Below
Skip to Confirmation
Message Below
During anal sex that last time, did you use a condom?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
Skip to Q30
Skip to Q30
Did you use the condom the whole time?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
Confirmation Message: Ask the following if Q23 and Q28 =0:
"So this means you only had oral sex the last time you had sex?"
30.
Before or during the last time you had sex with this partner, did you use:
[READ CHOICES. CHECK ONLY ONE.]
Alcohol…..….….………………..……………...
1
Drugs………..……………………………..……
2
Both alcohol and drugs ……………………........
3
Neither one….……………..…..…...….………..
4
Refused to answer.………..…….……...…….…
7
Don't know…..…..……….….….…….…...…..
9
NHBS Data Collection Instrument
July 2007
Skip to Q31
Skip to Q31
32
Core Questionnaire
30a.
31.
31a.
Which drugs did you use? [DO NOT read choices. Check all that apply.]
Marijuana ….……………..…..…...……….……….
1
Speedballs (heroin and cocaine together) .…………
2
Heroin ….……………..…..…...….…………….….
3
Crack Cocaine….……………..…..…...….………...
4
Powdered cocaine ….……………..…..…...….……
5
Crystal meth (tina, crank, ice) ….……………..……
6
X or Ecstasy ….……………..…..…...….………….
7
Special K (ketamine) ….……………..…..…...….…
8
GHB ….……………..…..…...….………………….
9
Painkillers (Oxycontin, Vicodin, Percocet) ….…….
10
Downers (Valium, Ativan, Xanax) ….…………….
11
Hallucinogens (LSD, mushrooms) ….……………...
12
Poppers ….……………..…..…...….………………
13
Other drug ......................................................……..
14
Refused to answer…………………..…….…….......
77
Don't know……………..……………...…..............
99
The last time you had sex with this partner, did you know her HIV status?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
Skip to Q32
Skip to Q32
What was her HIV status?
HIV-negative……………………………..…......
1
HIV-positive…...….…………………..………..
2
Indeterminate……………………………..…….
3
Refused to answer.……………………………...
7
NHBS Data Collection Instrument
July 2007
33
Core Questionnaire
32.
32a.
Was this partner younger than you, older than you, or the same age as you?
Younger ………………….………….………….
0
Older………………………………..…………...
1
Same age………………………………..………
2
Refused to answer…………………………..…..
7
Don't know……………..………….………......
9
What was her age?
Skip to Q33
Skip to Q33
___ ___ ___
[777 = Refused, 999 = Don't know]
33.
34.
35.
Has this partner ever injected drugs like heroin, cocaine, or speed?
No………………….………….………………..
0
Yes………………………………..………….....
1
Refused to answer…………………………..…..
7
Don't know……………..………….………......
9
Has this partner ever used crack cocaine?
No………………….………….………………..
0
Yes………………………………..………….....
1
Refused to answer…………………………..…..
7
Don't know……………..………….………......
9
Has this partner ever been in prison or jail for more than 24 hours?
No………………….………….………………..
0
Yes………………………………..………….....
1
Refused to answer…………………………..…..
7
Don't know……………..………….………......
9
NHBS Data Collection Instrument
July 2007
34
Core Questionnaire
Skip Pattern: If Q14a=3 or Q21=3, skip to Say Box before Q39.
36.
How long have you been having a sexual relationship with this partner?
[To the Interviewer: If length of relationship is < 1 month, enter "01" for months and "00"
for years. If < than 1 year, enter "00" for years and number of complete months.]
YEARS __ __
MONTHS __ __
[Refused = 77, Don't know = 99]
If Q36 is < 12 months, ask:
37.
As far as you know, during the time you were having a sexual relationship with this partner, did
she have sex with other people? Would you say she: [READ CHOICES, CHECK ONLY ONE.]
Definitely did not………………….……………
0
Probably did not………………………………..
1
Probably did……………………………………
2
Definitely did ………………….……………….
3
Refused to answer…………………………..…..
7
Don't know……………..………….………........
9
If Q36 is > 12 months, ask:
37.
As far as you know, during the past 12 months when you were having a sexual relationship with
this partner, did she have sex with other people? Would you say she: [READ CHOICES,
CHECK ONLY ONE.]
Definitely did not………………….……………
0
Probably did not………………………………..
1
Probably did……………………………………
2
Definitely did ………………….……………….
3
Refused to answer…………………………..…..
7
Don't know……………..………….………........
9
NHBS Data Collection Instrument
July 2007
35
Core Questionnaire
If Q36 is < 12 months, ask:
38.
During the time you were having a sexual relationship with this partner, did you have sex
with other people?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
If Q36 is > 12 months, ask:
38.
During the past 12 months when you were having a sexual relationship with this partner, did you
have sex with other people?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
Male Sex Partners (Male respondent)
SAY: Now I'm going to ask you some questions about having sex with other men. I need to ask you
these questions even if some don't apply to you. Please remember your answers will be kept private.
GIVE RESPONDENT FLASHCARD B.2
For these questions, "having sex" means oral or anal sex. Oral sex means he put his mouth on your
penis or you put your mouth on his penis. Anal sex means you put your penis in his anus (butt) or he
put his penis in your anus (butt).
39.
Have you ever had oral or anal sex with a man?
No………………….………….………………..
0
Yes………………………………..………….....
1
Refused to answer…………………………..…..
7
Don't know……………..………….………......
9
NHBS Data Collection Instrument
July 2007
Skip to Say Box before Q98
Skip to Say Box before Q98
36
Core Questionnaire
40.
How old were you the first time you had oral or anal sex with a man?
[77 = Refused, 99 = Don't know]
41.
__ __
In the past 12 months, with how many different men have you had oral or anal sex?
___ ___ ___ ___
[Refused = 7777, Don't know = 9999]
If 0, 7777, or 9999,
skip to Say Box before Q98
Skip Pattern for # of Male Sexual Partners: If Q41 =1, ask Q42a.
Otherwise, ask Q42.
FOR MULTIPLE MALE PARTNERS
[Read Say Box and Questions in this column]
SAY: Now I'm going to ask you to describe these sex
partners as either main, casual, or exchange partners.
FOR ONE MALE PARTNER
[Read Say Box and Question in this column]
SAY: Now I'm going to ask you to describe this sex
partner as either a main, casual, or exchange partner.
[GIVE RESPONDENT FLASHCARD D]
[GIVE RESPONDENT FLASHCARD D]
By “main partner” I mean a man you have sex with and
who you feel committed to above anyone else. This is a
partner you would call your boyfriend, significant other, or
life partner. By “casual partner” I mean a man you have
sex with but do not feel committed to or don't know very
well. And by "exchange partner" I mean a man you have
sex with in exchange for things like money or drugs.
By “main partner” I mean a man you have sex with and
who you feel committed to above anyone else. This is a
partner you would call your boyfriend, significant other,
or life partner. By “casual partner” I mean a man you
have sex with but do not feel committed to or don't know
very well. And by "exchange partner" I mean a man you
have sex with in exchange for things like money or
drugs.
Refused = 7777, Don't know = 9999
Question
Response
42. Of the _____ [insert
number from Q41] men you’ve
had oral or anal sex with in the
past 12 months, how many of
them were main partners?
43. How many were casual
partners?
44. How many were exchange
partners?
NHBS Data Collection Instrument
July 2007
[_____]
[_____]
Skip
Pattern
If Q42 =
Q41, skip to
Say Box
before
Q45a.
If Q42 +
Q43=Q41,
skip to Say
Box before
Q45a.
Question
42a. Was this man a main partner, a casual partner, or an
exchange partner?
Main partner……. ..
1
Skip to Q45a
Casual partner….....
2
Skip to Q46a
Exchange partner…
3
Skip to Q47a
Refused to answer...
7
Skip to Q48
Don’t know…….. ...
9
Skip to Q48
[_____]
37
Core Questionnaire
Skip Pattern For Multiple Male Partners:
If Q42 is not equal to 0, 7777, or 9999, go to Say Box below.
Otherwise, if Q43 is not equal to 0, 7777, or 9999, go to Say Box before Q46a.
Otherwise, if Q44 is not equal to 0, 7777, or 9999, go to Say Box before Q47a.
MAIN MALE PARTNERS
MULTIPLE MAIN MALE PARTNERS
[Read questions in this column]
Refused = 7777, Don't know = 9999
SAY: Now I'm going to ask you about the _______ [insert
number from Q41] male main sex partners you had in the
past 12 months. Remember, a main sex partner is someone
you feel committed to above anyone else.
Question
Response
Skip Pattern
ONE MAIN MALE PARTNER
[Read questions in this column]
No = 0, Yes = 1, Refused = 7, Don't know = 9
SAY: Now I'm going to ask you about the male
main sex partner you had in the past 12 months.
Remember, a main sex partner is someone you feel
committed to above anyone else.
Question
Response
Skip Pattern
45a. Of your ______ [insert
number from Q42] male
main partners in the past 12
months, with how many did
you have anal sex?
45a. In the past
12 months, did
you have anal sex
with this man?
45b. In the past 12 months,
with how many of these
______ [insert number from
Q45a] men did you have anal
sex without using a condom?
45c. Of your ____ [insert
number from Q42] male
main partners, with how
many did you have sex for the
first time in the past 12
months?
45d. With how many of these
____ [insert number from
Q45c] men did you discuss
BOTH your HIV status and
their HIV status before you
had sex for the first time?
[_____]
If 0, 7777, or
9999, skip to
Q45c.
[_____]
[_____]
[_____]
If 0, 7777, or
9999 AND
Q43 is not
equal to 0, skip
to Say Box
before Q46a.
45b. In the past
12 months, did
you have anal sex
with him without
using a condom?
45c. Did you
have sex with this
man for the first
time in the past
12 months?
45d. Did you
discuss BOTH
your HIV status
and his HIV
status before you
had sex for the
first time?
[_____]
If 0, 7, or 9, skip
to say box before
Q45c.
[_____]
[_____]
[_____]
If 0, 7, or 9 AND
Q42a=1, skip to
Q48. Otherwise, if
0, 7, or 9, AND
Q43 are not equal
to 0, skip to Say
Box before Q46a.
If Q42a=1, skip to
Q48.
Skip Pattern for Multiple Male Sex Partners:
If Q42=Q41, Skip to Q48.
Otherwise, if Q43 is not equal to 0, 7777, or 9999, go to Say Box before Q46a.
Otherwise, if Q44 is not equal to 0, 7777, or 9999, go to Say Box before Q47a.
NHBS Data Collection Instrument
July 2007
38
Core Questionnaire
CASUAL PARTNERS
MULTIPLE CASUAL MALE PARTNERS
[Read questions in this column]
Refused = 7777, Don't know = 9999
SAY: Now I'm going to ask you about the _______ [insert
number from Q43] male casual sex partners you had in the
past 12 months. Remember, a casual sex partner is someone
you do not feel committed to or don't know very well.
Question
Response Skip Pattern
ONE CASUAL MALE PARTNER
[Read questions in this column]
No = 0, Yes = 1, Refused = 7, Don't know = 9
SAY: Now I'm going to ask you about the male
casual sex partner you had in the past 12 months.
Remember, a casual sex partner is someone you
do not feel committed to or don't know very well.
Question
Response
Skip Pattern
46a. Of your ______ [insert
number from Q43] male casual
partners in the past 12 months,
with how many did you have
anal sex?
46a. In the past
12 months, did
you have anal
sex with this
man?
46b. In the past 12 months, with
how many of these ______
[insert number from Q46a]
men did you have anal sex
without using a condom?
46c. Of your ____ [insert
number from Q43] male casual
partners, with how many did
you have sex for the first time
in the past 12 months?
46d. With how many of these
____ [insert number from
Q46c] men did you discuss
BOTH your HIV status and
their HIV status before you had
sex for the first time?
[_____]
If 0, 7777, or
9999, skip to
Q46c.
[_____]
[_____]
[_____]
If 0, 7777, or
9999 AND
Q44 is not
equal to 0,
skip to Say
Box before
Q47a.
46b. In the past
12 months, did
you have anal
sex without
using a condom?
46c. Did you
have sex with
this man for the
first time in the
past 12 months?
46d. Did you
discuss BOTH
your HIV status
and his HIV
status before
you had sex for
the first time?
If 0, 7, or 9, skip
to Q46c.
[_____]
[_____]
[____]
[____]
If 0, 7, or 9 AND
Q42a=2, skip to
Q48. Otherwise,
if 0, 7, or 9,
AND Q44 are
not equal to 0,
skip to Say Box
before Q47a.
If Q42a=2, skip
to Q48.
Skip Pattern For Multiple Male Sex Partners:
If Q42 + Q43 = Q41, go to Q48.
Otherwise, go to Say Box before Q47a.
NHBS Data Collection Instrument
July 2007
39
Core Questionnaire
EXCHANGE PARTNERS
MULTIPLE EXCHANGE MALE PARTNERS
[Read questions in this column]
Refused = 7777, Don't know = 9999
SAY: Now I'm going to ask you about the _______ [insert
number from Q44] male exchange sex partners you had in the
past 12 months. Remember, an exchange partner is someone
you have sex with in exchange for things like money or drugs.
Question
47a. Of your ______ [insert
number from Q44] male
exchange partners in the past 12
months, with how many did you
have anal sex?
47b. With how many of these
______ [insert number from
Q47a] men did you have anal
sex without using a condom?
47c. Of your ______ [insert
number from Q44] male
exchange partners in the past 12
months, how many did you give
things like money or drugs in
exchange for sex?
47d. Of your ______ [insert
number from Q44] male
exchange partners in the past 12
months, how many gave you
things like money or drugs in
exchange for sex?
NHBS Data Collection Instrument
July 2007
Response
Skip Pattern
[_____]
If 0, 7777, or
9999, skip to
Q47c.
[_____]
[_____]
[_____]
ONE EXCHANGE MALE PARTNER
[Read questions in this column]
No = 0, Yes = 1, Refused = 7, Don't know = 9
SAY: Now I'm going to ask you about the male
exchange sex partner you had in the past 12
months. Remember, an exchange partner is
someone you have sex with in exchange for things
like money or drugs.
Question
Response
Skip
Pattern
47a. In the past 12
months, did you have
If 0, 7,
anal sex with this man?
or 9,
[_____] skip to
Q47c.
47b. In the past 12
months did you have
anal sex with him
without using a condom?
47c. In the past 12
months, did you give
this man things like
money or drugs in
exchange for sex?
47d. In the past 12
months, did this man
give you things like
money or drugs in
exchange for sex?
[_____]
[_____]
[_____]
40
Core Questionnaire
EXCHANGE PARTNERS (con't)
MULTIPLE EXCHANGE MALE PARTNERS
[Read questions in this column]
Refused = 7777, Don't know = 9999
Question
Response
Skip Pattern
47e. Of your ____ [insert
number from Q44] male
exchange partners, with how
many did you have sex for the
first time in the past 12
months?
47f. With how many of these
____ [insert number from
Q47e] men did you discuss
BOTH your HIV status and
their HIV status before you
had sex for the first time?
48.
[_____]
If 0, 7777, or
9999, skip to
Q48.
[_____]
ONE EXCHANGE MALE PARTNER
[Read questions in this column]
No = 0, Yes = 1, Refused = 7, Don't know = 9
Question
Response
Skip Pattern
47e. Did you have
sex with this man
for the first time in
the past 12 months?
[_____]
47f. Did you
discuss BOTH your
HIV status and his
HIV status before
you had sex for the
first time?
If 0, 7777, or
9999, skip to
Q48.
[_____]
Now I would like you to think about the last time you had sex with a man. When was the last
time you had anal or oral sex with a man? Just tell me the month and year.
[77/7777 = Refused, 99/9999 = Don't know]
__ __/ __ __ __ _
(M M / Y
Y
Y
Y)
Skip Pattern:
If Q42a=3, go to Q50.
Otherwise, if Q41=1, go to Q51.
Otherwise, if Q41>1, ask Q49.
49.
Was the man you had sex with that last time a main partner, a casual partner, or an exchange
partner?
Main sex partner………......................................
1
Casual sex partner………....................................
2
Exchange sex partner………...............................
3
Refused to answer................................................
7
Don’t know………..............................................
9
NHBS Data Collection Instrument
July 2007
Skip to Q51
Skip to Q51
41
Core Questionnaire
50.
51.
52.
52a.
When you had sex that last time, did you give him things in exchange for sex or did he give you
things in exchange for sex? [DO NOT read choices. Check only one.]
I gave him things in exchange for sex….……….
0
He gave me things in exchange for sex ………
1
Refused to answer…………………..…...………
7
Don't know…………….…………………........
9
When you had sex that last time, did you have receptive anal sex where he put his penis in your
anus (butt)?
No………….……………………………..…….
0
Yes……………………………………………..
1
Refused to answer…………………..…….…….
7
Don't know……..……………………...…........
9
Skip to Q53
Skip to Q53
During receptive anal sex that last time, did he use a condom?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
Skip to Q53
Skip to Q53
Did he use the condom the whole time?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
NHBS Data Collection Instrument
July 2007
42
Core Questionnaire
53.
When you had sex that last time, did you have insertive anal sex where you put your penis in his
anus (butt)?
Skip to Confirmation
0
No.……………………………………..………..
Message Below
Yes……………………………………………… 1
Refused to answer…………… …..…….………
Don't know……………..………………............
54.
7
9
Skip to Confirmation
Message Below
During insertive anal sex that last time, did you use a condom?
54a.
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
Skip to Q55
Skip to Q55
Did you use the condom the whole time?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
Confirmation Message: Ask the following if Q51 and Q53 =0:
"So this means you only had oral sex the last time you had sex?"
NHBS Data Collection Instrument
July 2007
43
Core Questionnaire
55.
Before or during the last time you had sex with this partner, did you use:
[READ CHOICES. CHECK ONLY ONE.]
Alcohol…..….….………………..……………...
1
Drugs………..……………………………..……
2
Both alcohol and drugs ……………………........
3
Neither one….……………..……..….………….
4
Refused to answer.………..…..……...…….…...
7
Don't know…..…..……….…...…….…...…......
55a.
Skip to Q56
Skip to Q56
9
Which drugs did you use? [DO NOT read choices. Check all that apply.]
Marijuana ….……………..…..…...……….……….
1
Speedballs (heroin and cocaine together) .…………
2
Heroin ….……………..…..…...….…………….….
3
Crack Cocaine….……………..…..…...….………...
4
Powdered cocaine ….……………..…..…...….……
5
Crystal meth (tina, crank, ice) ….……………..……
6
X or Ecstasy ….……………..…..…...….………….
7
Special K (ketamine) ….……………..…..…...….…
8
GHB ….……………..…..…...….………………….
9
Painkillers (Oxycontin, Vicodin, Percocet) ….…….
10
Downers (Valium, Ativan, Xanax) ….…………….
11
Hallucinogens (LSD, mushrooms) ….……………...
12
Poppers ….……………..…..…...….………………
13
Other drug ......................................................……..
14
Refused to answer…………………..…….…….......
77
Don't know……………..……………...…..............
99
NHBS Data Collection Instrument
July 2007
44
Core Questionnaire
56.
56a.
57.
57a.
The last time you had sex with this partner, did you know his HIV status?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
Skip to Q57
Skip to Q57
What was his HIV status?
HIV-negative……………………………..…….
1
HIV-positive…...….…………………..………..
2
Indeterminate……………………………..…….
3
Refused to answer.……………………………..
7
Was this partner younger than you, older than you, or the same age as you?
Younger ………………….………….………….
0
Older………………………………..…………...
1
Same age………………………………..………
2
Refused to answer…………………………..…..
7
Don't know……………..………….………......
9
What was his age?
Skip to Q58
Skip to Q58
___ ___ ___
[777 = Refused, 999 = Don't know]
58.
Has this partner ever injected drugs like heroin, cocaine, or speed?
No………………….…………………..……….
0
Yes………………………………………..……..
1
Refused to answer………………………………
7
Don't know……………..……………………..
9
NHBS Data Collection Instrument
July 2007
45
Core Questionnaire
59.
60.
Has this partner ever used crack cocaine?
No………………….………….………………..
0
Yes………………………………..………….....
1
Refused to answer…………………………..…..
7
Don't know……………..………….………......
9
Has this partner ever been in prison or jail for more than 24 hours?
No………………….………….………………..
0
Yes………………………………..………….....
1
Refused to answer…………………………..…..
7
Don't know……………..………….………......
9
Skip Pattern: If Q42a=3 or Q49=3, go to Q64.
61.
How long have you been having a sexual relationship with this partner? [To the Interviewer: If
length of relationship is < 1 month, enter "01" for months and "00" for years. If < than 1
year, enter "00" for years and number of complete months.]
YEARS __ __
MONTHS __ __
[Refused = 77, Don't know = 99]
NHBS Data Collection Instrument
July 2007
46
Core Questionnaire
If Q61 < 12 months, ask:
62.
As far as you know, during the time you were having a sexual relationship with this partner, did
he have sex with other people? Would you say he: READ CHOICES, CHECK ONLY ONE
Definitely did not………………….……………
0
Probably did not………………………………..
1
Probably did……………………………………
2
Definitely did ………………….……………….
3
Refused to answer…………………………..…..
7
Don't know……………..………….………......
9
If Q61 >12 months, ask:
62.
As far as you know, during the past 12 months when you were having a sexual relationship with
this partner, did he have sex with other people? Would you say he: READ CHOICES, CHECK
ONLY ONE
Definitely did not………………….……………
0
Probably did not………………………………..
1
Probably did……………………………………
2
Definitely did ………………….……………….
3
Refused to answer…………………………..…..
7
Don't know……………..………….………......
9
If Q61 < 12 months, ask:
63.
During the time you were having a sexual relationship with this partner, did you have sex
with other people?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
NHBS Data Collection Instrument
July 2007
47
Core Questionnaire
If Q61 >12 months, ask:
63.
During the past 12 months when you were having a sexual relationship with this partner, did you
have sex with other people?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
If Q61 < 3 years, ask:
64.
65.
Where did you first meet this partner? [DO NOT read choices. Check only one.]
Internet…….....….………………..…………….
01
Chat line….................................................
02
Bar/Club..………….............................………....
03
Circuit party or Rave….......................………….
04
Cruising area.………….........................………..
05
Adult bookstore…..…............................………..
06
Bath house, sex club or sex resort….....……….
07
Private sex party……...........................…………
08
Somewhere else.................................…………..
09
Refused to answer…………..….……………….
77
Don't know…..………..……..…………….......
99
In the past 12 months, how often have you gone to a place where gay men hangout, meet or
socialize? These could include bars, clubs, social organizations, parks, gay businesses,
bookstores, sex clubs, etc. Was it: [GIVE RESPONDENT FLASHCARD E. READ
CHOICES. CHECK ONLY ONE.]
Didn’t
More than
Once a
go
once a day
day
0........
1…….....
More than
Once
once a week a week
2 .………..
NHBS Data Collection Instrument
July 2007
3……..….
More than
once a month
4..…...…
Once a
Less than
a month once a month
5……..…..
6.…….…
Refused
Don’t
to answer Know
7…….…
77……..
48
..99
Core Questionnaire
66. In the past 12 months, how often did you use the internet to look for sex partners?
Was it: [GIVE RESPONDENT FLASHCARD F. READ CHOICES. CHECK ONLY ONE.]
Didn’t
use
More than
Once a
once a day
day
0........
1…….....
More than Once
More than
once a week a week once a month
2 .………..
3……..….
4..…...
Once a
a month
5……..……..
Less than
Refused
Don’t
once a month to answer Know
6.…….…
7…….…
77……
..99
Skip Pattern: If Q10 (Sexual Orientation)=1, ask Q67.
Otherwise, go to Say Box before Q98
67.
The next question is about whether you have told people that you are attracted to or have sex
with men. I’ll read a list of people you may have told, please tell me which ones apply.
Have you told: [READ CHOICES, CHECK ALL THAT APPLY]
Male friends who also have sex with other men…
1
Other friends…………….…………..………….
2
Family members……………………..………........
3
Spouse or partner……..…………….………...…..
4
Health care provider.……………………………..
5
No, haven’t told anyone….……………………….
0
Refused to answer……………………………..….
7
Don't know………….…………………………...
9
END OF MALE RESPONDENT SECTION.
GO TO SAY BOX BEFORE Q98
NHBS Data Collection Instrument
July 2007
49
Core Questionnaire
FOR FEMALE RESPONDENTS ONLY
Male Sex Partners (Female respondent)
68.
69.
Have you ever had vaginal or anal sex with a man?
No………………….……………………………
0
Yes……………………………………………...
1
Refused to answer………………………………
7
Don't know……………..……………………...
9
Skip to Say Box before Q98
How old were you the first time you had vaginal or anal sex with a man?
[77 = Refused, 99 = Don't know]
70.
Skip to Q97
__ __
In the past 12 months, with how many different men have you had oral, vaginal, or anal sex?
___ ___ ____ ____
[Refused = 7777, Don't know = 9999]
If 0, 7777, or 9999, skip to Say Box before
Q98
Skip Pattern for # of Male Sexual Partners:
If Q70 =1, ask Q71a.
Otherwise ask Q71.
NHBS Data Collection Instrument
July 2007
50
Core Questionnaire
FOR MULTIPLE MALE PARTNERS
[Read Say Box and Questions in this column]
SAY: Now I'm going to ask you to describe the sex
partners you've had in the past 12 months as either main,
casual, or exchange partners.
FOR ONE MALE PARTNER
[Read Say Box and Question in this column]
SAY: Now I'm going to ask you to describe this sex partner
you've had in the past 12 months as either a main, casual, or
exchange partner.
[GIVE RESPONDENT FLASHCARD D]
[GIVE RESPONDENT FLASHCARD D]
By “main partner” I mean a man you have sex with and
who you feel committed to above anyone else. This is a
partner you would call your boyfriend, husband,
significant other, or life partner. By “casual partner” I
mean a man you have sex with but do not feel committed
to or don't know very well. And by "exchange partner" I
mean a man you have sex with in exchange for things like
money or drugs.
By “main partner” I mean a man you have sex with and who
you feel committed to above anyone else. This is a partner
you would call your boyfriend, husband, significant other, or
life partner. By “casual partner” I mean a man you have sex
with but do not feel committed to or don't know very well.
And by "exchange partner" I mean a man you have sex with
in exchange for things like money or drugs.
Refused = 7777, Don't know = 9999
Question
71. Of the _____ [insert
number from Q70] men you’ve
had oral, vaginal, or anal sex
with in the past 12 months, how
many of them were main
partners?
72. How many were casual
partners?
73. How many were exchange
partners?
Response
[_____]
[_____]
Skip
Pattern
Question
If Q71=
Q70, skip to
Say Box
before
Q74a.
71a. Was this man a main partner, a casual partner, or an
exchange partner?
If Q71+
Q72=Q70,
skip to Say
Box before
Q74a.
Main partner……. ..
1
Skip to Q74a
Casual partner….....
2
Skip to Q75a
Exchange partner…
3
Skip to Q76a
Refused to answer...
7
Skip to Q77
Don’t know…….. ...
9
Skip to Q77
[_____]
Skip Pattern for Multiple Male Partners:
If Q71 is not equal to 0, 7777, or 9999, go to Say Box below.
Otherwise, if Q72 is not equal to 0, 7777, or 9999, go to Say Box before Q75a.
Otherwise, if Q73 is not equal to 0, 7777, or 9999, go to Say Box before Q76a.
NHBS Data Collection Instrument
July 2007
51
Core Questionnaire
MULTIPLE MALE PARTNERS
MULTIPLE MAIN MALE PARTNERS
[Read questions in this column]
Refused = 7777, Don't know = 9999
SAY: Now I'm going to ask you about the _______ [insert
number from Q70] male main sex partners you had in the past
12 months. Remember, a main sex partner is someone you
feel committed to above anyone else.
Question
Response
Skip Pattern
ONE MAIN MALE PARTNER
[Read questions in this column]
No = 0, Yes = 1, Refused = 7, Don't know = 9
SAY: Now I'm going to ask you about the male main
sex partner you had in the past 12 months. Remember, a
main sex partner is someone you feel committed to
above anyone else.
Question
Response
Skip Pattern
74a. Of your ______ [insert
number from Q71] male
main partners in the past 12
months, with how many did
you have vaginal sex?
74a. In the past 12
months, did you
have vaginal sex
with this man?
74b. In the past 12 months,
with how many of these
______ [insert number from
Q74a] men did you have
vaginal sex without using a
condom?
74c. Of your ______ [insert
number from Q71] male
main partners in the past 12
months, with how many did
you have anal sex?
74d. With how many of these
______ [insert number from
Q74c] men did you have anal
sex without using a condom?
[_____]
If 0, 7777, or
9999, skip to
Q74c.
74b. In the past 12
months, did you
have vaginal sex
with him without
using a condom?
[_____]
[_____]
[_____]
NHBS Data Collection Instrument
July 2007
If 0, 7777, or
9999, skip to
Q74e.
74c. In the past 12
months, did you
have anal sex with
this man?
74d. In the past 12
months, did you
have anal sex with
him without using a
condom?
If 0, 7, or 9, skip
to Q74c.
[_____]
[_____]
[_____]
If 0, 7, or 9, skip
to say box before
Q74e.
[_____]
52
Core Questionnaire
MULTIPLE MALE PARTNERS (con't)
MULTIPLE MAIN MALE PARTNERS
[Read questions in this column]
Refused = 7777, Don't know = 9999
Question
Response
Skip Pattern
74e. Of your ____ [insert
If 0, 7777, or
number from Q71] male
9999 AND Q72
[_____]
main partners, with how
is not equal to 0,
many did you have sex for the
skip to Say Box
first time in the past 12
before Q75a.
months?
ONE MAIN MALE PARTNER
[Read questions in this column]
No = 0, Yes = 1, Refused = 7, Don't know = 9
Question
Response
Skip Pattern
74e. Did you have
If 0, 7, or 9 AND
sex with this man
Q71a=1, skip to
[_____]
for the first time in
Q77. Otherwise if
the past 12 months?
74f. With how many of these
____ [insert number from
Q74e] men did you discuss
BOTH your HIV status and
their HIV status before you
had sex for the first time?
74f. Did you
discuss BOTH your
HIV status and his
HIV status before
you had sex for the
first time?
[_____]
0, 7, or 9, AND
Q72 are not equal
to 0, skip to Say
Box before Q75a.
[_____]
If Q71a=1, skip to
Q77.
Skip Pattern for Multiple Male Sex Partners:
If Q71=Q70, go to Q77.
Otherwise, if Q72 is not equal to 0, 7777, or 9999, go to Say Box before Q75a.
Otherwise, if Q73 is not equal to 0, 7777, or 9999, go to Say Box before Q76a.
NHBS Data Collection Instrument
July 2007
53
Core Questionnaire
CASUAL PARTNERS
MULTIPLE CASUAL MALE PARTNERS
[Read questions in this column]
Refused = 7777, Don't know = 9999
SAY: Now I'm going to ask you about the _______ [insert
number from Q71] male casual sex partners you had in the
past 12 months. Remember, a casual sex partner is someone
you do not feel committed to or don't know very well.
Question
Response
Skip Pattern
ONE CASUAL MALE PARTNER
[Read questions in this column]
No = 0, Yes = 1, Refused = 7, Don't know = 9
SAY: Now I'm going to ask you about male casual sex
partner you had in the past 12 months. Remember, a
casual sex partner is someone you do not feel
committed to or don't know very well.
Question
Response
Skip Pattern
75a. Of your ______ [insert
number from Q72] male
casual partners in the past 12
months, with how many did
you have vaginal sex?
75a. In the past
12 months, did
you have vaginal
sex with this
man?
75b. In the past 12 months,
with how many of these
______ [insert number from
Q75a] men did you have
vaginal sex without using a
condom?
75c. Of your ______ [insert
number from Q72] male
causal partners in the past 12
months, with how many did
you have anal sex?
75d. In the past 12 months,
with how many of these
______ [insert number from
Q75c] men did you have
anal sex without using a
condom?
75e. Of your ____ [insert
number from Q72] male
casual partners, with how
many did you have sex for
the first time in the past 12
months?
75f. With how many of these
____ [insert number from
Q75e] men did you discuss
BOTH your HIV status and
their HIV status before you
had sex for the first time?
NHBS Data Collection Instrument
July 2007
[_____]
If 0, 7777, or
9999, skip to
Q75c.
75b. In the past
12 months, did
you have vaginal
sex with him
without using a
condom?
[_____]
[_____]
If 0, 7777, or
9999, skip to
Q75e.
75d. In the past
12 months, did
you have anal sex
with him without
a using condom?
[_____]
[_____]
[_____]
75c. In the past
12 months, did
you have anal sex
with this man?
If 0, 7777, or
9999 AND
Q73 is not
equal to 0,
skip to Say
Box before
Q76a.
75e. Did you
have sex with this
man for the first
time in the past
12 months?
75f. Did you
discuss BOTH
your HIV status
and his HIV
status before you
had sex for the
first time?
If 0, 7, or 9, skip
to Q75c.
[_____]
[_____]
If 0, 7, or 9,
skip to Q75e.
[_____]
[_____]
[_____]
[_____]
If 0, 7, or 9 AND
Q71a =2, skip to
Q77. Otherwise, if
0, 7, or 9, AND
Q73 are not equal
to 0, skip to Say
Box before Q76a.
If Q71a=2, skip to
Q77.
54
Core Questionnaire
Skip Pattern for Multiple Male Sex Partners:
If Q71 + Q72 = Q70, go to Q77. Otherwise, go to Say Box before Q76a.
EXCHANGE PARTNERS
MULTIPLE EXCHANGE MALE PARTNERS
[Read questions in this column]
Refused = 7777, Don't know = 9999
SAY: Now I'm going to ask you about the _______ [insert
number from Q73] male exchange sex partners you had in the
past 12 months. Remember, an exchange partner is someone
you have sex with in exchange for things like money or drugs.
Question
Response
Skip Pattern
ONE EXCHANGE MALE PARTNER
[Read questions in this column]
No = 0, Yes = 1, Refused = 7, Don't know = 9
SAY: Now I'm going to ask you about the male
exchange sex partner you had in the past 12 months.
Remember, an exchange partner is someone you have
sex with in exchange for things like money or drugs.
Question
Response
Skip Pattern
76a. Of your ______ [insert
number from Q73] male
exchange partners in the past
12 months, with how many
did you have vaginal sex?
76a. In the past 12
months, did you
have vaginal sex
this man?
76b. In the past 12 months,
with how many of these
______ [insert number from
Q76a] men, did you have
vaginal sex without using a
condom?
76c. Of your ______ [insert
number from Q73] male
exchange partners in the past
12 months, with how many
did you have anal sex?
76d. In the past 12 months,
with how many of these
______ [insert number from
Q76c] men, did you have anal
sex without using a condom?
NHBS Data Collection Instrument
July 2007
[_____]
If 0, 7777, or
999, skip to
Q76c.
76b. In the past 12
months, did you
have vaginal sex
with him without
using a condom?
[_____]
[_____]
[_____]
If 0, 7777, or
9999, skip to
Q76e.
76c. In the past 12
months, did you
have anal sex with
this man?
76d. In the past 12
months, did you
have anal sex with
him without using a
condom?
If 0, 7, or 9,
skip to Q76c.
[_____]
[_____]
If 0, 7, or 9,
skip to
Q76e.
[_____]
[_____]
55
Core Questionnaire
MULTIPLE EXCHANGE MALE PARTNERS
[Read questions in this column]
Refused = 7777, Don't know = 9999
Question
Response
Skip Pattern
76e. Of your ______ [insert
number from Q73] male
exchange partners in the past
12 months, how many did
you give things like money or
drugs in exchange for sex?
76f. Of your ______ [insert
number from Q73] male
exchange partners in the past
12 months, how many gave
you things like money or
drugs in exchange for sex?
76g. Of your ____ [insert
number from Q73] male
exchange partners, with how
many did you have sex for the
first time in the past 12
months?
76h. With how many of these
____ [insert number from
Q76g] men did you discuss
BOTH your HIV status and
their HIV status before you
had sex for the first time?
77.
76e. In the past 12
months, did you give
this man things like
money or drugs in
exchange for sex?
[_____]
76f. In the past 12
months, did this man
give you things like
money or drugs in
exchange for sex?
[_____]
[_____]
ONE EXCHANGE MALE PARTNER
[Read questions in this column]
No = 0, Yes = 1, Refused = 7, Don't know = 9
Question
Response Skip Pattern
If 0, 7777, or
9999, skip to
Q77.
[_____]
76g. Did you have
sex with this man for
the first time in the
past 12 months?
76h. Did you discuss
BOTH your HIV
status and his HIV
status before you had
sex for the first time?
[_____]
[_____]
If 0, 7, or 9,
skip to Q77.
[_____]
[_____]
Now I would like you to think about the last time you had sex with a man. When was the
last time you had oral, vaginal, or anal sex with a man? Just tell me the month and year.
[77/7777 = Refused, 99/9999 = Don't know]
__ __/ __ __ __ _
(M M / Y
Y
Y
Y)
Skip Pattern:
If Q71a=3, go to Q79.
Otherwise, if Q70=1, go to Q80.
Otherwise if Q70>1, ask Q78.
NHBS Data Collection Instrument
July 2007
56
Core Questionnaire
78.
79.
80.
81.
Was the man you had sex with that last time a main partner, a casual partner, or an exchange
partner?
Main sex partner………......................................
1
Casual sex partner………....................................
2
Exchange sex partner………...............................
3
Refused to answer................................................
7
Don’t know………..............................................
9
Skip to Q80
Skip to Q80
When you had sex that last time, did you give him things in exchange for sex or did he give you
things in exchange for sex? [DO NOT read choices. Check only one.]
I gave him things in exchange for sex….……….
0
He gave me things in exchange for sex ………
1
Refused to answer…………………..…...………
7
Don't know…………….…………………........
9
When you had sex that last time, did you have vaginal sex?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
Skip to Q85
Skip to Q85
During vaginal sex that last time, did you or your partner use a condom?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
NHBS Data Collection Instrument
July 2007
Skip to Q84
Skip to Q84
57
Core Questionnaire
81a.
82.
83.
84.
Did you or your partner use the condom the whole time?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
Did you or your partner use the condom to prevent pregnancy, to prevent infections like HIV or
other sexually transmitted diseases, to prevent both, or for some other reason?
Pregnancy ………………….…….….................
1
HIV/STDs…………………… ………………..
2
Both….…………………………………………
3
Other reason…………….…….....……………..
4
Refused to answer…………………..…….…….
7
Don't know……………..……………...…........
9
Skip to Q84
Skip to Q84
When you had vaginal sex that last time, were you or your partner using anything else besides
condoms to prevent pregnancy such as birth control pills, pulling out/withdrawal, not having sex
at certain times/rhythm, or other birth control methods?
No………………….………….………………...
0
Yes………………………………..…………......
1
Refused to answer…………………………..…..
7
Don't know……………..………….………......
9
Skip to Q85
When you had vaginal sex that last time, were you or your partner using anything to prevent
pregnancy such as birth control pills, having a vasectomy, having tubes tied, pulling
out/withdrawal, not having sex at certain times/rhythm, or other birth control methods?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
NHBS Data Collection Instrument
July 2007
58
Core Questionnaire
85.
86.
86a.
When you had sex that last time, did you have anal sex?
No……………………………………………….
0
Yes……………………………………..………..
1
Refused to answer………………….…………..
7
Don't know…….…………………………........
9
Skip to Confirmation
Message Below
Skip to Confirmation
Message Below
During anal sex that last time, did your partner use a condom?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
Skip to Q87
Skip to Q87
Did he use the condom the whole time?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
Confirmation Message: Ask the following if Q80 and Q85=0:
"So this means you only had oral sex the last time you had sex?"
87.
Before or during the last time you had sex with this partner, did you use:
[READ CHOICES. CHECK ONLY ONE.]
Alcohol…..….….………………..……………...
1
Drugs………..……………………………..……
2
Both alcohol and drugs …………………….......
3
Neither one….……………..…..…...….………..
4
Refused to answer.………..…….……...…….…
7
Don't know…..…..……….….….…….…...…..
9
NHBS Data Collection Instrument
July 2007
Skip to Q88
Skip to Q88
59
Core Questionnaire
87a.
88.
88a.
Which drugs did you use? [DO NOT read choices. Check all that apply.]
Marijuana ….……………..…..…...……….……….
1
Speedballs (heroin and cocaine together) .…………
2
Heroin ….……………..…..…...….…………….….
3
Crack Cocaine….……………..…..…...….………...
4
Powdered cocaine ….……………..…..…...….……
5
Crystal meth (tina, crank, ice) ….……………..……
6
X or Ecstasy ….……………..…..…...….………….
7
Special K (ketamine) ….……………..…..…...….…
8
GHB ….……………..…..…...….………………….
9
Painkillers (Oxycontin, Vicodin, Percocet) ….…….
10
Downers (Valium, Ativan, Xanax) ….…………….
11
Hallucinogens (LSD, mushrooms) ….……………...
12
Poppers ….……………..…..…...….………………
13
Other drug ......................................................……..
14
Refused to answer…………………..…….…….......
77
Don't know……………..……………...…..............
99
The last time you had sex with this partner, did you know his HIV status?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
Skip to Q89
Skip to Q89
What was his HIV status?
HIV-negative……………………………..…......
1
HIV-positive…...….…………………..………..
2
Indeterminate……………………………..…….
3
Refused to answer.……………………………...
7
NHBS Data Collection Instrument
July 2007
60
Core Questionnaire
89.
89a.
Was this partner younger than you, older than you, or the same age as you?
Younger ………………….………….………….
0
Older………………………………..…………...
1
Same age………………………………..………
2
Refused to answer…………………………..…..
7
Don't know……………..………….………......
9
What was his age?
Skip to Q90
Skip to Q90
___ ___ ___
[777 = Refused, 999 = Don't know]
90.
91.
92.
Has this partner ever injected drugs like heroin, cocaine, or speed?
No………………….………….………………...
0
Yes………………………………..…………......
1
Refused to answer…………………………..…..
7
Don't know……………..………….………......
9
Has this partner ever used crack cocaine?
No………………….………….………………..
0
Yes………………………………..………….....
1
Refused to answer…………………………..…..
7
Don't know……………..………….………......
9
Has this partner ever been in prison or jail for more than 24 hours?
No………………….………….………………..
0
Yes………………………………..………….....
1
Refused to answer…………………………..…..
7
Don't know……………..………….………......
9
NHBS Data Collection Instrument
July 2007
61
Core Questionnaire
93.
Has this partner ever had sex with other men?
No………………….……………….…………..
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
Skip Pattern: If Q71a=3 or Q78=3, go to Say Box before Q98
94.
How long have you been having a sexual relationship with this partner? [To the Interviewer: If
length of relationship is < 1 month, enter "01" for months and "00" for years. If < than 1
year, enter "00" for years and number of complete months.]
YEARS __ __
MONTHS __ __
[Refused = 77, Don't know = 99]
If Q94< 12 months, ask:
95.
As far as you know, during the time you were having a sexual relationship with this partner, did
he have sex with other people? Would you say he: [READ CHOICES, CHECK ONLY ONE]
Definitely did not………………….……………
0
Probably did not………………………………..
1
Probably did……………………………………
2
Definitely did ………………….……………….
3
Refused to answer…………………………..…..
7
Don't know……………..………….……….......
9
NHBS Data Collection Instrument
July 2007
62
Core Questionnaire
If Q94 >12 months, ask:
95.
As far as you know, during the past 12 months when you were having a sexual relationship with
this partner, did he have sex with other people? Would you say he: [READ CHOICES, CHECK
ONLY ONE]
Definitely did not………………….……………
0
Probably did not………………………………..
1
Probably did……………………………………
2
Definitely did ………………….……………….
3
Refused to answer…………………………..…..
7
Don't know……………..………….……….......
9
If Q94 < 12 months, ask:
96.
During the time you were having a sexual relationship with this partner, did you have sex
with other people?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
If Q94 > 12 months, ask:
96.
During the past 12 months when you were having a sexual relationship with this partner, did you
have sex with other people?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
NHBS Data Collection Instrument
July 2007
63
Core Questionnaire
Female Sex Partners (Female Respondents)
97. Now I’m going to ask you about having sex with other women. In the past 12 months, with how
many different women have you had sex?
[Refused = 7777, Don't know = 9999] ___ ___ ____ ____
ALCOHOL USE HISTORY
SAY: The next questions are about alcohol use. Please remember your answers will be kept private.
For these questions, "a drink of alcohol" means a 12 oz beer, a 5 oz glass of wine, or a 1.5 oz shot of
liquor. SHOW RESPONDENT FLASHCARD G (PICTURE OF ALCOHOL DRINK SIZE)
98.
98a.
In the past 12 months, did you drink any alcohol such as beer, wine, malt liquor, or hard liquor?
No………………………………………………
0
Yes……………………………………………..
1
Refused to answer………………………………
7
Don't know…………………………………….
9
__ __
If 0, 77, or 99
Skip to
Q98d
On the days when you drank alcohol in the past 30 days, about how many drinks did you have
on average?
[77 = Refused, 99 = Don't know]
98c.
Skip to Say Box before Q99
In the past 30 days, on how many days did you drink any alcohol?
[77 = Refused, 99 = Don't know]
98b.
Skip to Say Box before Q99
__ __
In the past 30 days, how many times did you have 5 or more alcoholic drinks in one sitting?
[4 or more drinks if respondent is female.]
[77 = Refused, 99 = Don't know]
NHBS Data Collection Instrument
July 2007
__ __
64
Core Questionnaire
98d.
In the past 12 months, how often did you have 5 or more alcoholic drinks in one sitting?
[4 or more drinks if respondent is female.] GIVE RESPONDENT FLASHCARD H, READ
CHOICES. CHECK ONLY ONE.
Never….….…………………..…………………
0
More than once a day…..……………………….
1
Once a day………………………………………
2
More than once a week..……………………......
3
Once a week…………………………................
4
More than once a month………………………..
5
Once a month…..……………………………….
6
Less than once a month…..…………………….
7
Refused to answer……………..………………
77
Don’t know………..……………………………
99
DRUG USE HISTORY
Injection Drug Use
SAY: The next questions are about injection drug use. This means injecting drugs yourself or
having someone who isn't a health care provider inject you. Please remember your answers will
be kept private.
FOR NHBS-MSM AND NHBS-HET, ASK Q99
FOR NHBS-IDU, GO TO Q99a
99.
Have you ever in your life shot up or injected any drugs other than those prescribed for you? By
shooting up, I mean anytime you might have used drugs with a needle, either by mainlining, skin
popping, or muscling.
No………………….……………………………
0
Yes………………………………………………
1
Refused to answer………………………………
7
Don't know……………..……………………...
9
NHBS Data Collection Instrument
July 2007
Skip to Say Box before Q121
Skip to Say Box before Q121
65
Core Questionnaire
99a.
Think back to the very first time you injected any drugs, other than those prescribed for you.
How old were you when you first injected any drug?
[77 = Refused, 99 = Don't know]
__ __
FOR NHBS-MSM AND NHBS-HET, ASK Q99b.
FOR NHBS-IDU, SKIP TO SAY BOX BEFORE Q100
99b.
When was the last time you injected any drug? That is, how many days or months or years ago
did you last inject?
[Interviewer: If respondent answers today, enter “000” in # of Days field]
# of Days:
__ __ __
# of Months: __ __ __
# of Years:
__ __ __
[Refused = 777, Don't know = 999]
If Q99b > 12 months, skip to Say Box before Q121
SAY: The next questions are about injection drug use in the past 12 months. When I ask
you about "needles," I'm talking about needles and syringes.
100.
In the past 12 months when you injected, did you get your needles at any of the following
places? [GIVE RESPONDENT FLASHCARD I; READ ALL CHOICES]
No
Yes
Refused Don’t
to answer know
a. Pharmacy or drug store ……... …………………………………..
0…
1…
7….
9
b. Doctor’s office, clinic, or hospital…………………………….......
0…
1…
7….
9
c. Friend, acquaintance, relative, or sex partner………………..……
0…
1…
7….
9
d. Needle or drug dealer, shooting gallery, hit house, off the street....
0…
1…
7….
9
e. Needle exchange program………………………………………...
0…
1…
7….
9
f. Some other place………………………………………………….
(Specify ___________________________)
0…
1…
7….
9
NHBS Data Collection Instrument
July 2007
66
Core Questionnaire
101.
In the past 12 months when you injected, how often did you use a new, sterile needle? By a new,
sterile needle, I mean a needle never used before by anyone, even you.
[GIVE RESPONDENT FLASHCARD J, READ CHOICES. CHECK ONLY ONE.]
Never……….…….…………………..…………
0
Rarely…………….……………….……..…….
1
About half the time……………………………..
2
Most of the time…..……..……………………...
3
Always.….……………..……………………….
4
Refused to answer…..…………………………..
7
Don’t know………..……………………………
9
SAY: I'm going to read you a list of drugs. For each drug I mention, please tell me how often you
injected it in the past 12 months. GIVE RESPONDENT FLASHCARD F
102.
How often did you inject:
READ EACH DRUG CHOICE. CHOOSE ONLY ONE RESPONSE PER TYPE OF DRUG
Didn't
use
a. Heroin and cocaine
together (speedballs)..
b. Heroin alone………..
c. Powdered cocaine
alone………………..
d. Crack cocaine………
e. Crystal meth (tina,
crank, or ice)……....
f. Oxycontin………..…
g. Other injected drug…
(Specify___________)
00..
00..
More
than
once a
day
Once a
day
More
than
once a
week
Once a
week
More
than
once a
month
Once a
month
Less
than
once a
month
Refused
to answer
01….. 02….. 03…... 04…… 05…..... 06……. 07…… 77
01….. 02….. 03…... 04…… 05…..... 06……. 07…… 77
00… 01….. 02….. 03…... 04…… 05…..... 06……. 07…… 77
00… 01….. 02….. 03…... 04…… 05……. 06…… 07……. 77
00..
00..
00..
NHBS Data Collection Instrument
July 2007
01….. 02….. 03…... 04…… 05…..... 06……. 07……. 77
01….. 02….. 03…... 04…… 05…..... 06……. 07……. 77
01….. 02….. 03…... 04……. 05….... 06……. 07……. 77
67
Core Questionnaire
SAY: Next, I'm going to ask you about your injecting behaviors in the past 12 months.
103.
In the past 12 months, with how many people did you use a needle after they injected with it?
[Refused = 777, Don't know = 999]
104.
In the past 12 months, with how many people did you use the same cooker, cotton, or water that
they had already used. By “water,” I mean water for rinsing needles or preparing drugs.
[Refused = 777, Don't know = 999]
105.
__ __ __
In the past 12 months, with how many people did you use drugs that had been divided with a
syringe that they had already used?
[Refused = 777, Don't know = 999]
106.
__ __ __
__ __ __
In the past 12 months, how often did you use needles that someone else had already injected
with? [GIVE RESPONDENT FLASHCARD J, READ CHOICES. CHECK ONLY ONE]
Never……….…….…………………..…………
0
Rarely…………….……………….……..…….
1
About half the time……………………………..
2
Most of the time…..……..……………………...
3
Always.….……………..……………………….
4
Refused to answer……………..………………..
7
Don’t know………..……………………………
9
NHBS Data Collection Instrument
July 2007
68
Core Questionnaire
FOR NHBS-IDU, ASK Q107-Q109 THEN SKIP TO Q111
107.
108.
109.
In the past 12 months when you injected, how often did you use a cooker that someone else had
already used? [GIVE RESPONDENT FLASHCARD J, READ CHOICES, CHECK ONLY
ONE.]
Never……….…….…………………..…………
0
Rarely…………….……………….……..……...
1
About half the time……………………………..
2
Most of the time…..……..……………………...
3
Always.….……………..……………………….
4
Refused to answer……………..………………..
7
Don’t know………..……………………………
9
In the past 12 months when you injected, how often did you use a cotton that someone else had
already used? [GIVE RESPONDENT FLASHCARD J, READ CHOICES, CHECK ONLY
ONE.]
Never……….…….…………………..…………
0
Rarely…………….……………….……..……...
1
About half the time……………………………..
2
Most of the time…..……..……………………...
3
Always.….……………..……………………….
4
Refused to answer……………..………………..
7
In the past 12 months when you injected, how often did you use water that someone else had
already used? [GIVE RESPONDENT FLASHCARD J, READ CHOICES, CHECK ONLY
ONE.]
Never……….…….…………………..…………
0
Rarely…………….……………….……..……...
1
About half the time……………………………..
2
Most of the time…..……..……………………...
3
Always.….……………..……………………….
4
Refused to answer……………..………………..
7
NHBS Data Collection Instrument
July 2007
69
Core Questionnaire
FOR NHBS-MSM AND NHBS-HET, ASK Q110
110.
111.
In the past 12 months when you injected, how often did you use cookers, cottons, or water that
someone else had already used? [GIVE RESPONDENT FLASHCARD J, READ CHOICES,
CHECK ONLY ONE.]
Never……….…….…………………..…………
0
Rarely…………….……………….……..……...
1
About half the time……………………………..
2
Most of the time…..……..……………………...
3
Always.….……………..……………………….
4
Refused to answer……………..………………..
7
In the past 12 months when you injected, how often did you use drugs that had been divided with
a syringe that someone else had already injected with? [GIVE RESPONDENT FLASHCARD
J, READ CHOICES. CHECK ONLY ONE.]
Never……….…….…………………..…………
0
Rarely…………….……………….……..……..
1
About half the time…………………………….
2
Most of the time…..……..……………………...
3
Always.….……………..……………………….
4
Refused to answer……………..………………..
7
Don’t know………..……………………………
9
SAY: Now I’d like you to think about the last time you injected with someone.
112.
When was the last time you injected with someone?
[77/7777 = Refused, 99/9999 = Don't know]
__ __/ __ __ __ __
(M M / Y
NHBS Data Collection Instrument
July 2007
Y
Y
Y)
70
Core Questionnaire
If Q103 =0, Skip to Q114
113.
The last time you injected with this person, did you use a needle after they injected with it?
No………….……………………………………
0
Yes……………………………………………..
1
Refused to answer…………………………..…
7
Don't know……………..……………………...
9
Skip to 114
113a. Did you use a new sterile needle to inject?
No………….…………………………………..
0
Yes……………………………………………..
1
Refused to answer…………………………..….
7
Don't know……………..……………………...
9
If Q104 =0, Skip to Q115
114.
The last time you injected with this person, did you use the same cooker, cotton, or water that
they had already used?
No………….…………………………………..
0
Yes……………………………………………..
1
Refused to answer…………………………..…
7
Don't know……………..……………………..
9
NHBS Data Collection Instrument
July 2007
71
Core Questionnaire
If Q105 =0, Skip to Q116
115.
The last time you injected with this person, did you use drugs that had been divided with a
syringe that they had already injected with?
No………….…………………………………..
0
Yes……………………………………………..
1
Refused to answer…………………………..…
7
Don't know……………..……………………..
9
SAY: The next questions are about this last person you injected with.
116.
117.
118.
Is this person male or female?
Male………………………..…………..………
1
Female….…………………….……………..…
2
Other (specify______________)………………
3
Skip to Q118
Has this person ever had sex with another man?
No………….…………………………………..
0
Yes……………………………………………..
1
Refused to answer…………………………..…
7
Don't know……………..……………………..
9
The last time you injected with this person, did you know their HIV status?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
NHBS Data Collection Instrument
July 2007
Skip to Q119
Skip to Q119
72
Core Questionnaire
118a. What was their HIV status?
119.
HIV-negative……………………………..…......
1
HIV-positive…...….…………………..………..
2
Indeterminate……………………………..…….
3
Refused to answer.……………………………...
7
The last time you injected with this person, did you know if they had been tested for hepatitis C?
No………………….……………….…………...
0
Yes….……………………………….……..........
1
Refused to answer………………………..……..
7
Don't know.……………..………………..........
9
Skip to Q120
Skip to Q120
119a. What was the result of their hepatitis C test?
120.
Negative……………………………..….............
1
Positive…...….…………………..……….........
2
Refused to answer.……………………………...
7
Which of the following best describes you relationship to this person? Would you say this
person was a: [GIVE RESPONDENT FLASHCARD K. READ CHOICES, CHECK ONLY
ONE.]
Sex partner ……………………………….……
1
Friend or acquaintance …………………………
2
Relative …………………………………………
3
Needle or drug dealer…………………………..
4
Stranger..........................................……………..
5
Other (specify________________)…………….
6
Refused to answer………………...…………….
7
Don't know……………..……..…..…………..
9
NHBS Data Collection Instrument
July 2007
73
Core Questionnaire
FOR NHBS-IDU: IF QES17=0, SKIP TO INSTRUCTIONS BEFORE Q123
Non-Injection Drug Use
SAY: Now I’m going to ask you about drugs that you may have used but did not inject. I will refer to
these as non-injection drugs. This includes drugs like marijuana, crystal meth, cocaine, crack, club
drugs, painkillers, or poppers.
FOR NHBS-MSM AND NHBS-HET, ASK Q121
121.
In the past 12 months, have you used any non-injection drugs, other than those prescribed for
you?
No………………….…………………..………
0
Yes………………………………………..……
1
Refused to answer………………………………
7
Don't know……………..……………………..
9
If QES9=2, skip to Say Box before Q124;
If QES9=1, skip to Q123
If QES9=2, skip to Say Box before Q124;
If QES9=1, skip to Q123
SAY: I'm going to read you a list of drugs. For each drug I mention, please tell me how
often you used it in the past 12 months. Do not include drugs you injected or drugs that
were prescribed for you. GIVE RESPONDENT FLASHCARD H
122. How often did you use:
READ EACH DRUG CHOICE. CHOOSE ONLY ONE RESPONSE PER TYPE OF DRUG.
Didn't
use
More
than
once a
day
a. Crystal meth (tina, crank,
or ice)..……………………
00……
b. Crack cocaine…………….... 00……
c. Powdered cocaine that is smoked
or snorted…………...……
00……
d. Downers such as Valium,
Ativan, or Xanax.……
00……
e. Painkillers such as Oxycontin,
Vicodin, or Percocet, .…
00……
f. Hallucinogens such as LSD
or mushrooms……….…
00……
00……
g. X or Ectasy……………..
h. Special K (ketamine)……
00……
NHBS Data Collection Instrument
July 2007
Once a
day
More
than
once a
week
Once a
week
More
than
once a
month
Once a
month
Less
than
once a
month
Refused
to answer
01……
01…....
02…… 03…...
02…… 03…...
04…… 05…........
04…… 05….......
06……
07……… 77
06……… 07……… 77
01……
02……
03…...
04…… 05…........
06……… 07……… 77
01……. 02…… 03…...
04…… 05…........
06……… 07……… 77
01……
02…… 03…...
04…… 05…........
06……… 07……… 77
01……
01……
01……
02…… 03…...
02…… 03…...
02…… 03…...
04…… 05…........
04…… 05…........
04…… 05…........
06……… 07……… 77
06……… 07……… 77
06……… 07……… 77
74
Core Questionnaire
Didn't
use
i. GHB…………………
j. Heroin that is
smoked or snorted……..
k. Marijuana………………
l. Poppers ( amyl nitrate)...
m. Other drug……………….
More
than
once a
day
Once a
day
More
than
once a
week
Once a
week
More
than
once a
month
Once a
month
Less
than
once a
month
Refused
to answer
00…… 01…… 02…… 03…...
04…… 05…........
06……… 07……… 77
00……
00……
00……
00……
04…… 05…........
04…… 05…........
04…… 05…........
04…… 05…........
06………
06………
06………
06………
01……
01……
01……
01……
02……
02……
02……
02……
03…...
03…...
03…...
03……
07………
07………
07………
07………
77
77
77
77
(Specify___________)
If Respondent is female (QES9 =2), skip to Say Box before Q124.
123.
In the past 12 months, have you used Viagra, Levitra or Cialis?
No………….…………………………………..
0
Yes……………………………………………..
1
Refused to answer…………………………..….
7
Don't know……………..……………………...
9
Skip to Say Box before Q124
Skip to Say Box before Q124
123a. Did you use it to treat erectile dysfunction?
No………….…………………………………..
0
Yes……………………………………………..
1
Refused to answer…………………………..…
7
Don't know……………..……………………..
9
If Respondent is male (QES9=1) AND Q102e or Q122a are not 0 or
77, ask Q123b. Otherwise, skip to Say Box before Q124.
123b. You told me that you used crystal meth (tina, crank, ice). In the past 12 months, did you use
Viagra, Levitra or Cialis at the same time you used crystal meth?
No………….…………………………………..
0
Yes……………………………………………..
1
Refused to answer…………………………..….
7
Don't know……………..……………………...
9
NHBS Data Collection Instrument
July 2007
75
Core Questionnaire
ALCOHOL AND DRUG TREATMENT
SAY: Next, I’m going to ask you about alcohol and drug treatment programs. These include
out-patient, in-patient, residential, detox, methadone treatment, or 12-step programs.
124.
Have you ever participated in an alcohol or drug treatment program?
No………….…………………………………..
0
Yes……………………………………………..
1
Refused to answer…………………………..….
7
Don't know……………..……………………...
9
Skip to Say Box before Q125
Skip to Say Box before Q125
124a. Have you participated in an alcohol or drug treatment program in the past 12 months?
No………….…………………………………..
0
Yes……………………………………………..
1
Refused to answer…………………………..….
7
Don't know……………..……………………...
9
124b. In the past 12 months, did you try to get into an alcohol or drug treatment program but were
unable to?
No………….…………………………………..
0
Yes……………………………………………..
1
Refused to answer…………………………..….
7
Don't know……………..……………………...
9
NHBS Data Collection Instrument
July 2007
76
Core Questionnaire
HIV TESTING EXPERIENCES
SAY: Now I’m going to ask you a few questions about getting tested for HIV. Remember, an
HIV test checks whether someone has the virus that causes AIDS.
125.
126.
Have you ever been tested for HIV?
No…………………………...…………..............
0
Yes………………..……………………..............
1
Refused to answer………………………………
7
Don't know……………..……………………...
9
Skip to Q132
When did you have your first HIV test?
[77/7777 = Refused, 99/9999 = Don't know]
__ __/ __ __ __ __
(M M / Y
127.
Skip to Q131
Y
Y Y)
In the past 2 years, that is, since [insert calculated month and year], how many times have you
been tested for HIV?
___ ___ ___
[Refused = 777, Don't know = 999]
If 0, 777, or 999,
skip to Q129
If Q127=1, ask:
128.
That time you got tested for HIV in the past 2 years, did you get the result of the test? [Give
dates as reference points if needed.]
No…………………………...…………..............
0
Yes………………..……………………..............
1
Refused to answer………………………………
7
Don't know……………..……………………...
9
NHBS Data Collection Instrument
July 2007
Skip to Q129
Skip to Q129
77
Core Questionnaire
If Q127>1, ask:
128.
Of the ____ [insert number from Q127] times you were tested for HIV in the past 2 years, how
many times did you get the results of those tests? [Give dates as reference points if needed].
[Refused = 777, Don't know = 999]
___ ___ ___
If Q128= Q127
or if Q128=777 or 999, skip to Q129
128a. Think about the last time you didn’t get your HIV test result. What was the main reason you
didn’t get your result? [DO NOT read choices. Choose only one reason type.]
129.
Too early to get the result……………………….......
01
Thought site would contact them…………..………..
02
Afraid of getting result..…...……..………………….
03
Too busy to get the result………………...………….
04
Forgot to get result……………………………….
05
Didn’t care about result/didn’t want to know……….
06
Jail-related (released before getting result)…
07
Inconvenient (location/hours/time, etc)………...…..
08
Lost appointment card, paperwork, ID number ……
09
Other……………………..………………………….
10
Refused……………………………………………...
77
Don’t know…….....……..…………………………..
99
When did you have your most recent HIV test?
[77/7777 = Refused, 99/9999 = Don't know]
__ __/ __ __ __ __
(M M / Y
Y
Y
Y)
If Auto3 - Q129 is > 5 years ago, skip to Q129f.
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129a. When you got tested in ____/____ [insert date from Q129], where did you get tested?
Testing Site:________________________________________________________
[Write down the site name and classify it from the list of choices below. Probe with additional questions if
necessary. DO NOT read choices. Choose only one site type.]
HIV counseling and testing site……..……………… 01 ..
HIV/AIDS street outreach program/Mobile Unit…...
02
Sexually transmitted disease (STD) clinic…………..
03
Drug treatment program………………..………. …..
04
Needle exchange program.…...……..…………..…..
05
Correctional facility (jail or prison)……………. …..
06
Family planning clinic……………..…………..........
07
Prenatal/obstetrics clinic …………..…..………. …..
08
Public health clinic……,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, .
09
Community health center….…….……………….....
10
Private doctors office (including HMO)……….. …..
11
Emergency room………….……...……………….. ..
12
Hospital (inpatient)……………...….………….. …..
13
At home…………..………………………………....
14
Other………..………………………….………… ...
15
Refused……………………………………….... ......
77
Don’t know…….....……..……………………........ .
99
129b. When you got tested in _____/______ [insert date from Q129], did you get tested for any
of the following reasons:
No
Yes
Refused
to answer
Don’t
know
1. Because you thought or were worried you might have been
exposed to HIV in the 6 months before the test?………….……….
2. Because you got tested on a regular basis and it was time for you
0…
1…..
7….
9
to get tested again?………………………………………………….
3. Because you were just checking to make sure you were
0…
1…..
7….
9
HIV negative?....................................................................................
0…
1…..
7….
9
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Core Questionnaire
No
Yes
Refused
to answer
Don’t
know
4. Because your doctor or health care provider recommended you
get tested?....................................................................................
0…
1…..
7….
9
0…
1…..
7….
9
0…
1…..
7….
9
0…
1…..
7….
9
5. Because you were required to get tested by either insurance,
the military, a court order, or by some other agency………………..
FOR NHBS-IDU AND NHBS-HET: IF QES9=2 ASK Q129b.6
6. Because you were pregnant?...............................................................
7. Because there was some other reason you wanted to get
tested?.................................................................................................
(Specify other reason ___________________________)
129c. An anonymous HIV test means you were not required to give your name to get tested. You may
have been given an identification number or code to get your test results. When you got tested in
_____ / ______ [insert date from Q129], was it anonymous?
No………………….……………………………
0
Yes……………………………………...............
1
Refused to answer………………………………
7
Don't know……………..……………...............
9
129d. When you got tested in ____/____ [insert date from Q129], was it a rapid test where you could
get your results within a couple of hours?
No………………….……………………………
0
Yes………………………………………………
1
Refused to answer……………………………….
7
Don't know……………..……………………...
9
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Core Questionnaire
129e. Did the test in ____/____ [insert date from Q129] use a swab from your mouth, blood from your
finger, or blood from your arm?
Swab from mouth………………………………
1
Blood from finger…………………………….....
2
Blood from arm …………..…………………….
3
Other (specify ___________________)………..
4
Refuse to answer ……............………………….
7
Don’t know …………………………………….
9
129f. What was the result of your most recent HIV test? [DO NOT Read choices, check only one.]
Skip to Instructions before Q131
1
Negative………………….……………………..
130.
Positive………………………….………............
2
Never obtained results………………….….........
3
Indeterminate…………..……………..…………
4
Refused to answer…………...….……………….
7
Don't know…...…………………………..........
9
Skip to Q133
Skip to Q132
Before your test in ____/_____ [insert date from Q129], did you ever test positive for HIV?
No………………….……………………………
0
Yes……………………………………………...
1
Refused to answer………………………………
7
Don't know……………..……………………...
9
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July 2007
Skip to Q133a
81
Core Questionnaire
INTERVIEWER INSTRUCTIONS: Refer to answer to Q129.
LAST HIV TEST WAS DONE (Check one):
< 12 months ago...................................
Go to Q132
> 12 months ago...................................
Go to next question
Date of last test Don't know/Refused…
Go to Q132
[PERSONS WHO HAVE NOT TESTED FOR HIV IN THE PAST 12 MONTHS]
131.
I am going to read you a list of reasons why some people have not been tested for HIV. Please
tell me if the following are reasons why you have not been tested for HIV in the past 12 months.
I will read each reason and you should answer No or Yes for each one.
[READ CHOICES, CHECK NO OR YES FOR EACH ONE.]
Have you not been tested in the past 12 months:
Refused
No
Yes
to answer
a.
Because you think you are at low risk for HIV infection?....
0……..
1……..
7
b.
Because you were afraid of finding out that you had HIV?...
0……..
1……...
7
c.
Because you were worried your name would be
0………
1……..
7
d.
reported to the government if you tested positive?................
Because you were afraid of someone finding
out about the test result?.................................................…...
Because you were afraid of losing your job, insurance,
0………
1……..
7
e.
or housing if you tested positive?..........................................
0………
1……..
7
pay for the test?......................................................................
0………
1……..
7
g.
Because you didn’t have time?….…………….……….……
0……..
1……..
7
h.
Because you didn’t know where to go to get tested?.............
0……..
1……..
7
i.
Because you couldn’t get transportation to a testing place?..
0……..
1……..
7
j.
Because you don’t like needles?............................................
0……..
1……..
7
f.
Because you didn’t have the money or the insurance to
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July 2007
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Interviewer: If only one "yes" response in Q131a-j, then write the letter for the
"yes" response in Q131k. If more than one "yes" response for Q131a-j, ask Q131k.
131k. Which of these reasons was the most important reason you have not been tested for HIV in the
past 12 months? [Read each of the above reasons answered “Yes.” Write the letter of the main
reason in the box below. ]
[Refused to answer=7, Don’t know=9]
132.
_______
Some people take HIV or AIDS medicines because they think it might reduce their chances of
getting HIV. We don't know if this works. In the past 6 months, did you take any AIDS
medicines to reduce your chance of getting HIV? AIDS medicines are also known as
antireterovirals, HAART, or the AIDS cocktail.
No………………….……………………………
0
Yes………………………………………………
1
Refused to answer………………………………
7
Don't know………………………………………
9
Skip to Q135
[PERSONS WHO HAVE TESTED HIV POSITIVE]
133.
Was your test in ____/_____ [insert date from Q129] your first positive test?
No………………….……………………………
0
Yes………………………………………………
1
Refused to answer………………………………
7
Don't know…………………………………….
9
Skip to Q133e
133a. When did you first test positive?
[77/7777 = Refused, 99/9999 = Don't know]
__ __/ __ __ __ __
(M M / Y
NHBS Data Collection Instrument
July 2007
Y
Y
Y)
83
Core Questionnaire
133b. When you first tested positive in ____/______ [insert date from Q133a], where
did you get tested?
Testing Site:________________________________________________________
[Write down the site name and classify it from the list of choices below. Probe with
additional questions if necessary. DO NOT read choices. Choose only one site type.]
HIV counseling and testing site……..……………… 01 ..
HIV/AIDS street outreach program/Mobile Unit…...
02
Sexually transmitted disease (STD) clinic…………..
03
Drug treatment program………………..………. …..
04
Needle exchange program.…...……..…………..…..
05
Correctional facility (jail or prison)……………. …..
06
Family planning clinic……………..…………..........
07
Prenatal/obstetrics clinic …………..…..………. …..
08
Public health clinic……,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, .
09
Community health center….…….……………….....
10
Private doctors office (including HMO)……….. …..
11
Emergency room………….……...……………….. ..
12
Hospital (inpatient)……………...….………….. …..
13
At home…………..………………………………....
14
Other………..………………………….………… ...
15
Refused……………………………………….... ......
77
Don’t know…….....……..……………………..........
99
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July 2007
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Core Questionnaire
133c. When you got tested in ____/____ [insert date from 133a], did you get tested for any of the
following reasons:
No
Yes
Refused
to answer
Don’t
know
1. Because you thought or were worried you might have been
exposed to HIV in the 6 months before the test?…………………..
2. Because you got tested on a regular basis and it was time for you
0…
1…..
7….
9
to get tested again?………………………………………………….
3. Because you were just checking to make sure you were
0…
1…..
7….
9
HIV negative?.……………………………………………………..
4. Because your doctor or health care provider recommended you
0…
1…..
7….
9
get tested?....................................................................................
0…
1…..
7….
9
0…
1…..
7….
9
0…
1…..
7….
9
0…
1…..
7….
9
5. Because you were required to get tested by either insurance,
the military, a court order, or by some other agency………………..
FOR NHBS-IDU AND NHBS-HET: IF QES9=2 ASK Q133c.6
6. Because you were pregnant?...............................................................
7. Because there was some other reason you wanted to get
tested?.................................................................................................
(Specify other reason ___________________________)
133d. When you first tested positive in _____ / ______ [insert date from Q133a], was it anonymous?
[Repeat definition of "anonymous test" if needed: "An anonymous HIV test means you were
not required to give your name to get tested. You may have been given an identification
number or code to get your test results."]
No………………….……………………………
0
Yes……………………………………................
1
Refused to answer………………………………
7
Don't know…………….……………………….
9
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July 2007
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Core Questionnaire
133e. After you tested positive, were you asked by someone from the health department or your health
care provider to give the names of your sex or drug use partners so they could be notified that
they may have been exposed to HIV?
Skip to Q133g
0
No………………….……………………………
Yes……………………………………................
1
Refused to answer………………………………
7
Don't know……………..……………………...
9
Skip to Q133g
133f. Did you give the names of any of your partners when asked?
No………………….……………………………
0
Yes……………………………………...............
1
Refused to answer………………………………
7
Don't know……………..……………...............
9
Skip to Q133g
133f.1 What is the main reason you didn’t give any names of your partners when asked?
[DO NOT Read reason type. Choose only one reason.]
Didn’t know their name(s) or how to contact them...............
01
Wanted to contact them personally....…………………........
02
In shock, busy coping, or couldn’t think clearly at the time..
03
Afraid HD/Provider would give my name to my partner(s)..
04
Afraid partner(s) would react badly if they found out……. ..
05
Didn’t care whether partner(s) knew they may
be infected or exposed ……………………...…….….....
06
My partner(s) already knew they were positive…….............
07
Other……………………..………………………….............
08
Refused……………………………………………………...
77
Don’t know….……..………………...……………………..
99
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July 2007
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Core Questionnaire
133g. Before your first positive test in _____ / ______ [insert date from Q129 or Q133a], did
you ever have a negative HIV test? (By negative HIV test, I mean the test showed you did not
have HIV infection.)
No………………….……………………………
0
Yes……………………………………................
1
Refused to answer………………………………
7
Don't know…………….……………………….
9
Skip to Q133h
Skip to Q133h
133g.1 What was the month and year that you got your last negative HIV test? Tell me when you
got your last test, not when you got your results.
[77/7777 = Refused, 99/9999 = Don't know]
__ __/ __ __ __ __
(M M / Y
Y
Y Y)
133h. In the 2 years before your first positive test in _____ / ______ [insert date from Q129 or
Q133a], how many times did you get tested for HIV? Don't include your first positive test in
that total number.
[Refused = 7777, Don't know = 9999]
133i.
___ ___ ___ ___
Some people take HIV or AIDS medicines because they think it might reduce their chances of
getting HIV. We don't know if this works. In the 6 months before your first positive test, did
you take any AIDS medicines to reduce your chance of getting HIV? AIDS medicines are also
known as antireterovirals, HAART, or the AIDS cocktail.
No………………….……………………………
0
Yes……………………………………................
1
Refused to answer………………………………
7
Don't know…………….……………………….
9
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July 2007
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Core Questionnaire
133j. Have you ever been seen by a doctor, nurse, or other health care provider for a medical
evaluation or care related to your HIV infection?
No………………….……………………………
0
Yes……………………………………………...
1
Refused to answer………………………………
7
Don't know……………..……….......................
9
Skip to Q133k
Skip to Q134
133j.1. What is the main reason you have never gone to a health care provider for a medical evaluation
or care related to your HIV infection? [DO NOT read choices. Choose only one reason.]
Feel good, don't need to go …………………..…………
01
Don't want to think about being HIV positive/Denial…..
02
Didn’t have money or insurance…..………….………..
Couldn't find health care provider/Didn’t know
03
where to go…………….………….................................
04
Inconvenient (location/hours/time, etc.)....……………..
05
Forgot to go/Missed appointment……………..………..
06
Too busy to go…………...…...……..…………….........
07
Drinking or using drugs………….…………….............
08
On the street…………………………………….............
09
Appointment pending………..………………………….
10
Other……………………..……………………………..
11
Refused…………………………………………………
77
Don’t know……………………..………………….........
99
NHBS Data Collection Instrument
July 2007
Skip to Q135
88
Core Questionnaire
133k. When did you first go to your health care provider after learning you had HIV?
[77/7777=Refused, 99/9999 = Don't know]
__ __/ __ __ __ __
(M M / Y
Y
Y
Y)
INTERVIEWER INSTRUCTIONS: Refer to date of first positive HIV test (Q129 or Q133a)
< 3 months before first provider visit
Skip to Q133m
> 3 months before first provider visit
Go to next question
Interval cannot be determined (date missing)
Skip to Q133m
133l. Some people go to a health care provider soon after learning they are positive. What is the main
reason you didn’t go to a health care provider soon after you learned of your HIV infection? [DO
NOT read choices. Choose only one reason.]
Felt good, didn’t need to go …………………..…...........
01
Didn't want to think about being HIV positive/Denial….
02
Didn’t have money or insurance…..………….………..
Couldn't find health care provider/Didn’t know
03
where to go…………….………….................................
04
Inconvenient (location/hours/time, etc.)....……………..
05
Forgot to go/Missed appointment……………..………..
06
Too busy to go…………...…...……..…………….........
07
Drinking or using drugs………….…………….............
08
On the street…………………………………….............
09
Unable to get an earlier appointment………..………….
10
Other……………………..……………………………..
11
Refused………………………………………………....
77
Don’t know……………………..………………….........
99
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July 2007
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Core Questionnaire
133m. When did you last go to your health care provider for HIV care?
[77/7777=Refused, 99/9999 = Don't know]
__ __/ __ __ __ __
(M M / Y
Y
Y Y)
INTERVIEWER INSTRUCTIONS:
< 6 months since last provider visit
Skip to Q134
> 6 months since last provider visit
Go to next question
Interval cannot be determined (date missing)
Skip to Q134
133n. What is the main reason you have not gone to a health care provider for HIV care in the
past 6 months? [DO NOT Read reason types. Choose only one reason.]
Felt good, didn’t need to go …………………..…..........
01
Initial CD4 count and viral load were good…………….
02
Don't want to think about being HIV positive/Denial…..
03
Didn’t have money or insurance…..………….………..
Couldn't find health care provider/Didn’t know
04
where to go…………….………….................................
05
Inconvenient (location/hours/time, etc.)....……………..
06
Forgot to go/Missed appointment……………..………..
07
Too busy to go…………...…...……..…………….........
08
Drinking or using drugs………….…………….............
09
On the street…………………………………….............
10
Appointment pending………..………………………….
11
Other……………………..……………………………..
12
Refused…………………………………………………
77
Don’t know……………...……..………………….........
99
NHBS Data Collection Instrument
July 2007
90
Core Questionnaire
134.
134a.
Are you currently taking medicines to treat your HIV infection? These medicines are also
known as antiretroviral medicines, HAART, or the AIDS cocktail.
No………………….…………………..………
0
Yes………………………………………..…….
1
Refused to answer……………………………..
7
Don't know……………..………………...........
9
Skip to Q134b
Skip to Q135
Have you ever given your AIDS medicines to a sex partner who was HIV-negative because you
thought it might protect them for getting HIV?
No………………….…………………..………
0
Yes………………………………………..…….
1
Refused to answer……………………………..
7
Don't know……………..………………...........
9
Skip to Q135
134b. What is the main reason you are not currently taking any antiretroviral medicines?
[DO NOT read reason types. Choose only one reason.]
Feel good, don’t need them......……..………………….
01
CD4 count and viral load are good……….....................
02
Doctor advised to delay treatment…..………….............
03
Don't want to think about being HIV positive./Denial…
04
Worried about side effects …..………..…….….............
05
Don't have money or insurance……….…………....…..
06
Drinking or using drugs…………..…..…….…………..
07
On the street.…………………………..…….…............
08
Recently into medical care……………………………...
09
Other……………………..……………………..............
10
Refused…………………………………………………
77
Don’t know……………………….……………….........
99
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Core Questionnaire
135.
As far as you know, when someone visits their doctor for a regular check-up or exam, is it
routine practice to perform a test for HIV, or do they have to ask their doctor to perform this test?
Routine practice ……………………………….
1
Have to ask ……………………………………
2
Refused to answer………………………..……
7
Don’t know.……………..………………………
9
Interviewer Instructions: If interview day = 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, 24, 26,
28, or 30, skip to Q136b; Otherwise, ask Q136a
136a. I’m going to read two statements. Tell me which comes closer to your opinion:
[GIVE RESPONDENT FLASHCARD L]
A-- HIV testing should be treated just like routine screening for other diseases, and should be
included as part of regular check-ups and exams; or B-- HIV testing should be treated differently
from routine screening for other diseases, and should require special procedures, such as written
permission from the patient in order to perform the test.
A (routine screening) ………………………….
1
B (special procedures) …………………….......
2
Refused to answer………………………..…….
7
Don’t know.……………..………………………
9
Skip to Say Box before Q137
136b. I’m going to read two statements. Tell me which comes closer to your opinion:
[GIVE RESPONDENT FLASHCARD M ]
A-- HIV testing should be treated differently from routine screening for other diseases, and
should require special procedures, such as written permission from the patient in order to
perform the test; or B-- HIV testing should be treated just like routine screening for other
diseases, and should be included as part of regular check-ups and exams.
A (special procedures) ………………………….
1
B (routine screening) …………………………..
2
Refused to answer………………………..……..
7
Don’t know.……………..……………………...
9
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Core Questionnaire
HEALTH CONDITIONS
SAY: Next, I'd like to ask you some questions about your health.
If Respondent is Male (QES9 =1), ask Q137
137. Have you been circumcised? [IF NEEDED, SHOW FLASHCARD N]
No……………………..………………...............
0
Yes………………………..………….…………
1
Refused to answer…………………..…………..
7
Don't know…………….……………..................
9
Skip to Q138
Skip to Q138
137a. Were you circumcised after December 2005?
No……………………..………………...............
0
Yes………………………..………….…………
1
Refused to answer…………………..…………..
7
Don't know…………….……………..................
9
Skip to Q138
Skip to Q138
137b. Why did you get circumcised?
[DO NOT Read reason type. Choose all that apply. ]
To prevent HIV…………………………………..................
01
To prevent other STD(s)....………………….......................
02
For a medical problem……………………………………..
03
At partner's request………………………………………...
04
To increase sexual pleasure…… ...........................................
05
For hygiene……………..……………………...…….….....
06
Cultural/religious reasons………………………….............
07
Other……………………..………………………….............
If Other: Specify__________________
08
Refused……………………………………………………...
77
Don’t know….……..………………...……………………..
99
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Core Questionnaire
138.
The next questions are about hepatitis, an infection of the liver.
Has a doctor, nurse or other health care provider ever told you that you had hepatitis?
Skip to Q140
0
No………………….……………………………
Yes………………………….…………...............
1
Refused to answer………………………………
7
Don't know……………..……………................
9
Skip to Q140
138a. What type or types of hepatitis have you had? [CHECK ALL THAT APPLY.]
Hepatitis A……….……………………………..
0
Hepatitis B………………….…………..............
1
Hepatitis C……………………………...............
3
Other……………..…………….……………….
If Other: Specify__________________
4
Refused to answer………………………………
7
Don't know……………..……………................
9
NHBS Data Collection Instrument
July 2007
Skip to Q140
Skip to Q140
94
Core Questionnaire
139.
When were you told you had hepatitis C?
[READ CHOICES]
6 months ago or less.……………………………
0
More than 6 months ago, but less than 1 year.….
1
1 year ago or more………………………………
2
Refused to answer…………………..…………..
7
Don't know……………..…………...…………
9
139a. Have you ever taken medicine to treat your hepatitis C infection?
140.
No……………………..………………...............
0
Yes………………………..………….………….
1
Refused to answer…………………..…………..
7
Don't know……………..…………...…………
9
Skip to Instructions before Q141
Now I'm going to ask you about getting tested for hepatitis C. Have you ever had a blood
test to check for hepatitis C infection?
Skip to Instructions before Q141
No……………………..………………...............
0
Yes………………………..………….…………
1
Refused to answer…………………..…………..
7
Don't know………..………………...…………
9
Skip to Instructions before Q141
140a. When did you have your most recent hepatitis C test?
[READ CHOICES. CHECK ONLY ONE]
6 months ago or less.…………………..………..
0
More than 6 months ago, but less than 1 year…..
1
1 year ago or more………………………………
2
Refused to answer…………………..…………..
7
Don't know……………..…………...…………
9
NHBS Data Collection Instrument
July 2007
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Core Questionnaire
If Q138a=1 AND (Q129f = 2 OR Q130 =1), ask Q141;
Otherwise, if Q138a=1 AND (Q129f NE 2 and 130 NE 1), ask Q142;
Otherwise, if Q138a NE 1, skip to Q143
SAY: Now I'm going to ask you about treatment for Hepatitis B.
141.
142.
143.
You told me that you tested positive for HIV. In the 6 months before your first positive HIV
test, did you take any medicines to treat your Hepatitis B infection?
No………………….……………………………
0
Yes………………………….…………...............
1
Refused to answer………………………………
7
Don't know……………..……………................
9
Skip to Q143
In the past 6 months, did you take any medicines to treat your Hepatitis B infection?
No………………….……………………………
0
Yes………………………….…………...............
1
Refused to answer………………………………
7
Don't know……………..……………................
9
There are vaccines or shots that can prevent some types of hepatitis.
Have you ever had a hepatitis vaccine?
Skip to Q144
0
No………………….……………………………
Yes……………………………………................
1
Refused to answer…………………..…………..
7
Don't know……..…………………...…………
9
NHBS Data Collection Instrument
July 2007
Skip to Q144
96
Core Questionnaire
143a. What type or types of hepatitis vaccine have you had?
[READ CHOICES. CHECK ONLY ONE]
144.
Hepatitis A vaccine..…………………………….
1
Hepatitis B vaccine……………………………...
2
Hepatitis A and B vaccines………..……………
3
Refused to answer..………………..……………
7
Don't know………………..…………...............
9
Now I’m going to ask you some questions about sexually transmitted diseases or STDs.
In the past 12 months, has a doctor, nurse, or other health care provider told you that you had any
of the following STDs? [READ CHOICES, CHECK NO OR YES FOR EACH ONE]
No
Yes
Refused
to answer
Don’t
Know
a. Syphilis……………..…
0......…
1……..
7…………
9
b. Gonorrhea (clap or drip)..
0......…
1……..
7…………
9
c. Chlamydia…………..….
0......…
1……..
7……..…..
9
d. Genital herpes (HSV) .…
0........
1…….
7……..…..
9
e. Genital warts (HPV)……
0......…
1……..
7…………
9
7……..…..
9
f. Any Other STDs…..……
0......…
1……..
f.1 If Yes: Specify__________________
THE FOLLOWING QUESTION IS ASKED SEPARATELY FOR RESPONDENTS WHO
ANSWERED YES TO 144A-F.1. IF USING A PAPER QUESTIONNAIRE, RECORD
RESPONSES ON FORM 1.
144a.1- In the past 12 months, how many different times did you have _________?
144f.1 INSERT EACH STD RESPONDENT SAID YES TO IN Q144A-F.1
[Refused = 777, Don't know = 999]
___ ___ ___
NHBS Data Collection Instrument
July 2007
97
Core Questionnaire
IF Q144A=0, ASK Q144AA. OTHERWISE, SKIP TO Q145.
144aa. Even though a health care provider didn't tell you that you had syphilis, did you have a test to
check for syphilis in the past 12 months?
No……………………..………………..............
0
Yes………………………..………….…………
1
Refused to answer………………………………
7
Don't know……………..……………...............
9
HIV TESTING IN JAIL
145.
Now I will ask about HIV testing experiences you may have had with the criminal justice
system. Please remember your answers will be kept private.
In the past 12 months, have you been arrested by the police and booked?
No………………….……………………………
0
Yes………………………………….…………...
1
Refused to answer………………..……………..
7
Don't know….……………………...………….
9
Skip to Say Box Q148
Skip to Say Box Q148
145a. Think about the last time you were arrested and booked. How much time did you spend in
detention, jail, or prison?
[Up to 1 day=1, Refused = 777, Don't know = 999] Days = __ __ __
146.
The last time you were in detention, jail, or prison, did you get a test for HIV?
No……………………..………………...............
0
Yes………………………..………….…………
1
Refused to answer…………………..…………..
7
Don't know…………….…………….................
9
NHBS Data Collection Instrument
July 2007
Skip to Q147
Skip to Q147
98
Core Questionnaire
146a. Did you get the results of that HIV test?
147.
No………………….……………………………
0
Yes………………………..………….………….
1
Refused to answer…………………..…………..
7
Don't know……………..…………...………….
9
The last time you were in detention, jail, or prison, did you get a test for hepatitis C?
No……………………..………………...............
0
Yes………………………..………….…………
1
Refused to answer…………………..…………..
7
Don't know…………….…………….................
9
Skip to Say Box before Q148
Skip to Say Box before Q148
147a. Did you get the results of that hepatitis C test?
No………………….……………………………
0
Yes………………………..………….………….
1
Refused to answer…………………..…………..
7
Don't know……………..…………...………….
9
ASSESSMENT OF PREVENTION ACTIVITIES
SAY: Next I'd like to ask you about HIV prevention activities that happen around here.
148.
In the past 12 months, have you gotten any free condoms, not counting those given to you by a
friend, relative, or sex partner?
No…………….………………….……………..
0
Yes…………………………………..…………..
1
Refused to answer………………….…...............
7
Don’t Know………….………………………….
9
NHBS Data Collection Instrument
July 2007
If IDU in past 12 months, go to
Q149. Otherwise, skip to Q151
If IDU in past 12 months, go to
Q149. Otherwise, skip to Q151.
99
Core Questionnaire
148a. Did someone give you the condoms or did you pick them up?
Someone gave respondent condom………..…….
1
Respondent picked condom up…………………
2
Go to Q148bb
Both (Someone gave respondent condoms AND
the respondent picked condoms up)……… …….
3
Refused to answer………………………………
7
Don’t Know……………..………………………
9
Skip to Q149
148b. Which type of organization did the person who gave you the condom work for?
[ASK ABOUT EACH ORGANIZATION TYPE BELOW AND MARK THE APPROPRIATE
RESPONSE.]
No
Yes Refused Don’t
to answer know
1. HIV/AIDS-focused community-based organization………
0…
1….
7…
9
2. GLBTQ organization or community health center………
0…
1….
7…
9
3. Needle exchange program…………………………………
0…
1….
7…
9
4. IDU outreach program………………………………………
0…
1…..
7….
9
5. Community health center/public health clinic………………
0…
1….
7…
9
6. Drug treatment program……………………………………
0…
1….
7…
9
7. Business……………………………………………………
0…
1….
7…
9
8. School/university/college…………………………………...
0…
1….
7…
9
9. Pride or other similar event…………………………………
10. Other (Specify other reason ____________________)
0…
1….
7…
9
If Q148a =1,
Skip to
Q148c
148bb. When you picked-up the condoms, did you pick them up at any of the following places?
[ASK ABOUT EACH ORGANIZATION TYPE BELOW AND MARK THE APPROPRIATE
RESPONSE.]
No
Yes
Refused Don’t
to answer know
1. HIV/AIDS-focused community-based organization………
0…
1…..
7….
9
2. GLBTQ organization or community health center…………
0…
1…..
7….
9
3. Needle exchange program…………………………………
0…
1…..
7….
9
4. IDU outreach program………………………………………
0…
1…..
7….
9
5. Community health center/public health clinic…………….
0…
1…..
7…
9
NHBS Data Collection Instrument
July 2007
100
Core Questionnaire
No
Yes
Refused Don’t
to answer know
6. Drug treatment program…………………………………….
0…
1…..
7….
9
7. Businesses…………………………………………………..
0…
1…..
7….
9
8. School/university/college…………………………………
0…
1…..
7….
9
9. Pride or other similar event…………………………………
0…
1…..
7….
9
10. Other (Specify other reason ____________________)
0…
1…..
7….
9
148c. Have you used any of the free condoms you received?
149.
No………………….……………………………
0
Yes………………………..………….………….
1
Refused to answer……………………………….
7
Don’t Know…………………………………….
9
If IDU in past 12
months, go to Q149.
Otherwise, skip to Q151
In the past 12 months, have you gotten any new sterile needles for free, not including those given
to you by a friend, relative, or sex partner?
Skip to Q150
No…………….………………….……………..
0
Yes…………………………………..…………..
1
Refused to answer………………….…...............
7
Don’t Know………….………………………….
9
Skip to Q150
149a. Did you get the free sterile needles at any of the following places?
[ASK ABOUT EACH ORGANIZATION TYPE BELOW AND MARK THE APPROPRIATE
RESPONSE.]
No
Yes
Refused Don’t
to answer know
1. HIV/AIDS-focused community-based organization…………
0…
1…..
7….
9
2. Needle exchange program……………………………………
0…
1…..
7….
9
3. IDU outreach program………………………………………
0…
1…..
7….
9
4. Community health center/public health clinic……………….
0…
1…..
7…
9
5. Drug treatment program………………………………………
0…
1…..
7….
9
6. Other place……………………………………………………
0…
1…..
7….
9
NHBS Data Collection Instrument
July 2007
101
Core Questionnaire
149b. Have you used any of the free sterile needles you received?
150.
No………………….……………………………
0
Yes………………………..………….………….
1
Refused to answer……………………………….
7
Don’t Know…………………………………….
9
In the past 12 months, have you gotten any new cookers, cotton, or water for free, not
including those given to you by a friend, relative, or sex partner?
No…………….………………….……………..
0
Yes…………………………………..…………..
1
Refused to answer………………….…...............
7
Don’t Know………….………………………….
9
Skip to Q151
Skip to Q151
150a. Did you get those free items at any of the following places?
[ASK ABOUT EACH ORGANIZATION TYPE BELOW AND MARK THE APPROPRIATE
RESPONSE.]
No
Yes
Refused
to answer
Don’t
know
1. HIV/AIDS-focused community-based organization………………..
0…
1…..
7….
9
2. Needle exchange program………………………………………….
0…
1…..
7….
9
3. IDU outreach program………………………………………………
0…
1…..
7….
9
4. Community health center/public health clinic……………………..
0…
1…..
7….
9
5. Drug treatment program……………………………………………
0…
1…..
7….
9
6. Other place…………………………………………………………
0…
1…..
7….
9
150b. Have you used the free cookers, cotton, or water that you received?
No………………….……………………………
0
Yes………………………..………….………….
1
Refused to answer……………………………….
7
Don’t Know…………………………………….
9
NHBS Data Collection Instrument
July 2007
102
Core Questionnaire
151.
In the past 12 months, have you had a one-on-one conversation with an outreach worker,
counselor, or prevention program worker about ways to prevent HIV? Don’t count the times
when you had a conversation as part of an HIV test.
No………………….……………..……..............
0
Yes…………………………….………...............
1
Refused to answer…………………….………...
7
Don’t Know…………………………………….
9
Skip to Q152
Skip to Q152
151a. Which type of organization did they work for? [ASK ABOUT EACH ORGANIZATION TYPE
BELOW AND MARK THE APPROPRIATE RESPONSE.]
No
Yes
Refused
to answer
Don’t
know
1. HIV/AIDS-focused community-based organization………………..
0…
1…..
7….
9
2. GLBTQ organization or community health center……………….
0…
1…..
7….
9
3. Needle exchange program………………………………………….
0…
1…..
7….
9
4. IDU outreach program………………………………………………
0…
1…..
7….
9
5. Community health center/public health clinic……………………..
0…
1…..
7…
9
6. Drug treatment program……………………………………………
0…
1…..
7….
9
7. Business……………………………………………………………..
0…
1…..
7….
9
8. School/university/college…………………………………………..
0…
1…..
7….
9
9. Pride or other similar event…………………………………………
10. Other (Specify other reason ___________________________)
0…
1…..
7….
9
151b. During those one-on-one conversation(s), did you:
[ASK EACH QUESTION, MARK NO OR YES FOR EACH]
No
Yes
Refused Don't
to answer Know
1. Discuss ways to talk to a partner about safe sex?....
If yes, ask:
0…
1…
7……….
9
2. Practice ways to talk to a partner about safe sex?........
0....
1…
7……….
9
3. Discuss ways to effectively use condoms?…...……..
If yes, ask:
0…
1…
7……….
9
NHBS Data Collection Instrument
July 2007
103
Core Questionnaire
No
4. Practice ways to effectively use condoms?..................
Yes
Refused Don't
to answer Know
0…
1…..
7……….
9
5. Discuss how to prepare for safe injections?…...…….
If yes, ask:
0…
1…..
7……….
9
6. Practice safe drug-injecting practices?……….....……
0…
1…..
7……….
9
[If IDU in past 12 months, ask:]
152.
In the past 12 months have you been a participant in any organized session(s) involving a small
group of people to discuss ways to prevent HIV? Don't include discussions you had with a group
of friends.
No………………….……………………………
0
Yes………………………..………….………….
1
Refused to answer…………………..…...............
7
Don’t Know…………………………...………...
9
Skip to Q153
Skip to Q153
152a. Which type of organization sponsored those sessions?
[ASK ABOUT EACH ORGANIZATION TYPE BELOW AND MARK THE APPROPRIATE
RESPONSE.]
No
Yes
Refused
to answer
Don’t
know
1. HIV/AIDS-focused community-based organization………………..
0…
1….
7….
9
2. GLBTQ organization or community health center……………….
0…
1….
7….
9
3. Needle exchange program………………………………………….
0…
1….
7….
9
4. IDU outreach program………………………………………………
0…
1….
7….
9
5. Community health center/public health clinic……………………..
0…
1….
7….
9
6. Drug treatment program……………………………………………
0…
1….
7….
9
7. Business……………………………………………………………..
0…
1….
7….
9
8. School/university/college…………………………………………..
0…
1….
7….
9
9. Pride or other similar event…………………………………………
10. Other (Specify other reason ___________________________)
0…
1….
7….
9
NHBS Data Collection Instrument
July 2007
104
Core Questionnaire
152b. During those organized group session(s), did you:
[ASK EACH QUESTION, MARK NO OR YES FOR EACH.]
No
Yes
Refused Don't
to answer Know
1. Discuss ways to talk to a partner about safe sex?....
If yes, ask:
0…
1…
7……….
9
2. Practice ways to talk to a partner about safe sex?........
0....
1…
7……….
9
3. Discuss ways to effectively use condoms?…...……..
If yes, ask:
0…
1…
7……….
9
4. Practice ways to effectively use condoms?..................
0…
1…
7……….
9
5. Discuss how to prepare for safe injections?…...…….
If yes, ask:
0…
1…
7……….
9
6. Practice safe drug-injecting practices?……….....……
0…
1…
7……….
9
[If IDU in past 12 months, ask:]
BEFORE BEGINNING THE LOCAL QUESTIONS, THE INTERVIEWER ANSWERS THE
FOLLOWING QUESTION. DO NOT READ THIS TO THE RESPONDENT.
153. How confident are you of the validity of the respondent’s answers?
Confident….…………………..………………
1
Some doubts………………………..…………
2
Not confident at all…………………..…..........
3
If response is 2 or 3, please explain why you are not confident in the respondent's answers:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Auto5.
Time core questionnaire ended: __ __:__ __
NHBS Data Collection Instrument
July 2007
1 AM
2 PM
105
Core Questionnaire
FOR NHBS-HET CYCLE
Confirmation Message about Eligibility to Receive RDS Coupons:
If CITY = (RDS Sites) AND HRA=1: "This respondent is eligible to receive RDS
coupons."
To the Interviewer: Do you have any additional comments to add?
If yes, enter comments below:
Interviewer Comments
Say:
Do you have any questions about the issues we've talked about?
Thank the respondent for their time and end the interview.
NHBS Data Collection Instrument
July 2007
106
Recruiter Questions
National HIV Behavioral Surveillance System: Recruiter Questions
FOR NHBS-HET and IDU CYCLES
These questions are asked when participants return to receive payment for recruiting their peers.
R1.
How many of the coupons did you give out?
[Refused= 7, Don’t Know= 9] ___
R2.
Has anyone refused the coupons?
No………………………………………………………...
0
Yes…………………………………….……………….…
1
R3a.
Of those who refused coupons, how many were male?
[Refused= 77, Don’t Know= 99]
___ ___
R3b.
Of those who refused coupons, how many were female?
[Refused= 77, Don’t Know= 99]
___ ___
Skip to END
SAY: What is the race or ethnic background of the __ [insert number from R2] people who
refused coupons? That is, how many were white, black, Hispanic, or another race?
R3c.
White [Refused= 777, Don’t Know= 999] ___ ___ ___
R3d.
Black [Refused= 777, Don’t Know= 999] ___ ___ ___
R3e.
Hispanic [Refused= 777, Don’t Know= 999] ___ ___ ___
R3f
Another Race [Refused= 777, Don’t Know= 999] ___ ___ ___
NHBS Data Collection Instrument
July 2007
107
Recruiter Questions
R4.
Which of the following are reasons that people who refused gave you about why they did
not take a coupon?
(Read each one, Check all that apply)
They didn’t have time…………………..............
01
They didn’t live in the area……………………..
02
They didn’t trust you (recruiter)………………..
03
They don’t like research/surveys…………….…
04
They already participated in this survey………..
05
They weren’t eligible………………….………..
06
Some other reason……………............................
(Specify)____________
07
Refused…………………………………………
77
Don’t Know…………………………….............
99
NHBS Data Collection Instrument
July 2007
108
Flashcards
National HIV Behavioral Surveillance System: Flashcards
NETWORK FLASHCARD FOR NHBS-HET
How many people do you know who are:
•
•
•
•
Friends, relatives, or other people you are close to, AND
Who are at least 18 years of age, AND
Who live in [insert project area], AND
Who you have seen in the past 30 days
FLASHCARD A
Monthly Income
Yearly Income
a. 0 to $417…………………..a. 0 to $4,999
b. $418 to $833………………b. $5,000 to $9,999
c. $834 to $1250……………..c. $10,000 to $14,999
d. $1251 to $1667……………d. $15,000 to $19,999
e. $1668 to $2500……………e. $20,000 to $29,999
f. $2501 to $3333…………….f. $30,000 to $39,999
g. $3334 to $4167……………g. $40,000 to $49,999
h. $4168 to $6250……………h. $50,000 to $74,999
i. $6251 or more……………...i. $75,000 or more
NHBS Data Collection Instrument
July 2007
109
Flashcards
FLASHCARD B.1
Definition of "Having Sex"
Oral, vaginal, or anal sex.
• Oral sex means mouth on the vagina or penis
•
Vaginal sex means penis in the vagina
• Anal sex means penis in the anus (butt)
FLASHCARD B.2
Definition of "Having Sex"
Oral or anal sex.
• Oral sex means mouth on the penis
• Anal sex means penis in the anus (butt)
NHBS Data Collection Instrument
July 2007
110
Flashcards
FLASHCARD C
Female Sex Partners
Main partner:
A woman you have sex with and who you feel committed to above anyone else.
This is a partner you would call your girlfriend, wife, significant other, or life
partner.
Casual partner:
A woman you have sex with but do not feel committed to or don't know very well.
Exchange partner:
A woman you have sex with specifically for things like money or drugs.
FLASHCARD D
Male Sex Partners
Main partner:
A man you have sex with and who you feel committed to above anyone else. This is a
partner you would call your boyfriend, husband, significant other, or life partner.
Casual partner:
A man you have sex with but do not feel committed to or don't know very well.
Exchange partner:
A man you have sex with specifically for things like money or drugs.
NHBS Data Collection Instrument
July 2007
111
Flashcards
FLASHCARD E
0. Didn't go
1. More than once a day
2. Once a day
3. More than once a week
4. Once a week
5. More than once a month
6. Once a month
7. Less than once a month
FLASHCARD F
0. Didn't use
1. More than once a day
2. Once a day
3. More than once a week
4. Once a week
5. More than once a month
6. Once a month
7. Less than once a month
NHBS Data Collection Instrument
July 2007
112
Flashcards
There are 2 Options for Flashcard G. Please choose one.
FLASHCARD G
FOR USE WITH ALCOHOL QUESTIONS
NHBS Data Collection Instrument
July 2007
113
Flashcards
FLASHCARD G
FOR USE WITH ALCOHOL QUESTIONS
1 Shot of Liquor
(Whisky, Vodka, Gin, etc.)
1.5 oz.
NHBS Data Collection Instrument
July 2007
1 Glass of Wine
1 Regular Beer
12 oz.
5 oz.
114
Flashcards
FLASHCARD H
0. Never
1. More than once a day
2. Once a day
3. More than once a week
4. Once a week
5. More than once a month
6. Once a month
7. Less than once a month
FLASHCARD I
a. Pharmacy or drug store
b. Doctor’s office, clinic, or hospital
c. Friend, acquaintance, relative, or sex partner
d. Needle or drug dealer, shooting gallery, hit house, off the street
e. Needle exchange program
NHBS Data Collection Instrument
July 2007
1
Flashcards
FLASHCARD J
0. Never
1. Rarely
2. About half the time
3. Most of the time
4. Always
FLASHCARD K
0. Sex partner
1. Friend or acquaintance
2. Relative
3. Needle or drug dealer
4. Stranger
NHBS Data Collection Instrument
July 2007
2
Flashcards
FLASHCARD L
A) HIV testing should be treated just like routine screening for other diseases, and
should be included as part of regular check-ups and exams.
B) HIV testing should be treated differently from routine screening for other diseases,
and should require special procedures, such as written permission from the patient
in order to perform the test.
FLASHCARD M
A) HIV testing should be treated differently from routine screening for other diseases,
and should require special procedures, such as written permission from the patient
in order to perform the test.
B) HIV testing should be treated just like routine screening for other diseases, and
should be included as part of regular check-ups and exams.
NHBS Data Collection Instrument
July 2007
3
Flashcards
FLASHCARD N
NHBS Data Collection Instrument
July 2007
4
Flashcards
FOR USE WITH A PAPER SURVEY ONLY:
FORM 1
Use this form to record responses for Q144a.1 - 144f.1 ONLY if the interviewer is
administering the paper version of the questionnaire.
IF RESPONDENT HAD SYPHILLIS, GONORRHEA, CHLAMYDIA, OR "OTHER" STD ASK
THE FOLLOWING:
144a.1
In the past 12 months, how many different times did you have syphilis?
[Refused = 777, Don't know = 999]
144b.1
In the past 12 months, how many different times did you have gonorrhea?
[Refused = 777, Don't know = 999]
144c.1
___ ___ ___
In the past 12 months, how many different times did you have genital warts?
[Refused = 777, Don't know = 999]
144f.1
___ ___ ___
In the past 12 months, how many different times did you have genital herpes?
[Refused = 777, Don't know = 999]
144e.1
___ ___ ___
In the past 12 months, how many different times did you have chlamydia?
[Refused = 777, Don't know = 999]
144d.1
___ ___ ___
___ ___ ___
In the past 12 months, how many different times did you have _________)? [Insert specify
response for 144f.1]?
[Refused = 777, Don't know = 999]
NHBS Data Collection Instrument
July 2007
___ ___ ___
5
| File Type | application/pdf |
| File Modified | 2007-09-05 |
| File Created | 2007-08-02 |