Paper and Pencil Questionnaire

Form Approved

OMB No. 0920-XXX

Expiration Date XX/XX/20XX

ATTACHMENT 3:

PAPER AND PENCIL QUESTIONAIRE

Statement of burden for paper and pencil questionnaire

Public reporting burden of this collection of information is estimated to average 10 minutes per response including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

Consumer Paper and Pencil Questionnaire

Knowledge, Attitudes, Beliefs about HIV

	True	False	Don't Know
a. People can get HIV even though they had sex with only one person.
b. There is still no cure for HIV/AIDS.
c. You can tell that somebody has HIV just by looking at them.
d. A man may be at risk for HIV if he had unprotected anal or vaginal sex with a woman. By unprotected, we mean sex without a condom.
e. There is a test available to tell whether a person has HIV.
f. Treatment and support programs are available to people like me who might test positive for HIV.
g. People are automatically tested for HIV when they go to the doctor if their blood is drawn.

	Strongly disagree	Disagree	Neither agree/disagree	Agree	Strongly Agree
a. HIV is not my problem.
b. There are medications available to treat HIV.
c. I don’t need to worry about getting HIV because I know everything about my girlfriend/partner.
d. HIV is not something I think about often.
e. Knowing my HIV status helps me take responsibility for myself.
f. Knowing my HIV status helps me take responsibility for others.
g. HIV is not a big problem in my community.
h. I should get tested for HIV because I may be at risk.
i. People need education to learn how to avoid getting HIV.
j. I am less likely than most people to get HIV.

HIV Testing

1. Which of the following best describes your HIV testing behavior?

I have never been tested and am not concerned that I am at risk

I have never been tested but have thought about getting tested to be sure I am okay.

I have been tested at least once, but not on a regular basis

I test regularly or after any situation where I might have been exposed to HIV

2. Have you ever been tested for HIV?

Yes (Skip  to Q4)

No

3. Below is a list of reasons why some people have not been tested for HIV. Which of these are the main reasons why you have not been tested? Please select one or more of the following reasons.

[MARK ALL THAT APPLY]

You have not been sexually active

You have not had unprotected sex

You were afraid to find out if you were HIV positive

You didn’t want to think about HIV or about being HIV positive

You didn’t think you were at risk of being HIV positive

You don’t like needles

You don’t trust the results to be kept private

You had to wait too long for the results

You didn’t know where to get tested

You trust your sex partner

Some other reason [SPECIFY ____________________________]

SKIP TO Q10

4. When was your last HIV test?

mm dd yy

5. Where did you have your last HIV test?

Private doctor

STD or AIDS clinic or testing site

Hospital or emergency room

Public health department

At home

Drug treatment facility

Other location (SPECIFY__________________)

6. How was the HIV test given to you?

blood was drawn from your vein

your finger was pricked and blood was taken from the prick

your mouth was swabbed

7. Which of these are the main reasons for your last HIV test? Please select one or more of the following reasons.

[MARK ALL THAT APPY]

Just to find out, worried that you are infected

A doctor, nurse or other health care provider asked you to

The Health Department asked you to

Your sex partner asked you to

Because of your sex partner’s pregnancy

You found out your sex partner cheated

Already had an STD

You were starting a new relationship

Other reason [SPECIFY ____________________]

8. How often do you get an HIV test?

_______________________________________________

8. Do you get an HIV test after any situation when you think you might have been exposed to HIV?

Yes

No

8. Do you know a place where you can get an HIV test?

Yes

No (Skip  to Q14)

8. Is this place in your community?

Yes

No

8. Do you know a place where you can get a FREE HIV test?

Yes

No (Skip  to Q14)

8. Is this place in your community?

Yes

No

8. Have you talked to your partner about the importance of getting an HIV test?

Yes

No

8. It is important to get tested for HIV so that people who test positive can start getting treated right away. (strongly agree, agree, neither agree/disagree, disagree, strongly disagree)

Strongly disagree	Disagree	Neither agree/disagree	Agree	Strongly Agree

8. Have you ever talked to anyone, other than your partner, such as friends or family, about getting an HIV test?

Yes

No

8. When should you get an HIV test after having unprotected sex with a woman?

0-3 months	3-6 months	7-12 months	more than 12 months

8. If a free test was available to see if you have HIV, would you take it?

Yes

No

8. Have you ever seen or heard of any ads on TV or radio with the following themes or slogans?

KNOW HIV/AIDS

Yes

No

Rap it Up

Yes

No

Get tested. Get the results. Get on with your life.

Yes

No

Take Charge. Take the Test.

Yes

No

You know him. But you can’t know everything.

Yes

No

False campaign name to be determined

Yes

No

Risk Behaviors

These next few questions are about your personal behaviors including sexual activity. Please remember that your answers are kept private.

1. During the past 12 months, how many people did you have sex with?

NUMBER ________

How many of these people were women? ________

How many of these people were men? ________

2. How often did you and your sex partners use a condom?

Never

Occasionally

Usually

Always

Demographics

1. How old are you?

________

2. What is the highest grade or year of school you finished?

Never attended school or only attended kindergarten
Grades 1 through 8 (elementary)
Grades 9 through 11 (some high school)
Grade 12 or GED (high school graduate)
College 1 year to 3 years (some college or technical school)
College 4 years or more (college graduate)

3. What is your annual household income from all sources?

No income

Less than $5,000
$5,000-$9,999
$10,000-$14,999

$15,000-$19,999

$20,000-$24,999

$25,000-$29,999

$30,000-$34,999

$35,000-$39,999

$40,000-$44,999

$45,000-$49,999

$50,000-or above

4. Do you have a primary care doctor?

Yes

No

5. Do you have health insurance?

Yes

No (Skip  to End)

6. What kind of health insurance do you have (Please mark all that apply)

Medicare, a federal govt. program for people age 65 or older and certain disabled people

Medicaid, a state program that helps people w/low income

The military, TRICARE, or the VA

The Indian Health Service

Some other source (please specify) _______________________________________________________

END

8 of 8