Page 1 of 12
2007 NHIS Questionnaire - Sample Adult
AIDS Knowledge & Attitudes
Document Version Date: 12-Jul-06
Question ID: ADS.010_00.000 Instrument Variable Name: BLDGV QuestionnaireFileName: Sample Adult
QuestionText: Now, I am going to ask about giving blood donations to a blood bank such as the American Red Cross.
Have you donated blood since March 1985?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto BLDG12M]
<2,R,D> [goto HIVTST]
Question ID: ADS.020_00.000 Instrument Variable Name: BLDG12M QuestionnaireFileName: Sample Adult
QuestionText: During the PAST 12 MONTHS, that is, since [fill: 12-month ref. Date], have you donated blood?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have given blood since March 1985
SkipInstructions: <1,2,R,D> [goto HIVTST]
Question ID: ADS.040_00.000 Instrument Variable Name: HIVTST QuestionnaireFileName: Sample Adult
QuestionText: The next questions are about the test for HIV (the virus that causes AIDS).
[fill: Except for tests you may have had as part of blood donations, have you ever been tested for HIV?/Have you ever been
tested for HIV?]
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto TST12M_M]
<2> [goto WHYTST]
<R,D> [goto EXTST12M]
Page 2 of 12
2007 NHIS Questionnaire - Sample Adult
AIDS Knowledge & Attitudes
Document Version Date: 12-Jul-06
Question ID: ADS.050_00.000 Instrument Variable Name: WHYTST QuestionnaireFileName: Sample Adult
QuestionText: (book) A14
I am going to show you a list of reasons why some people have not been tested for HIV (the virus that causes AIDS).
Which one of these would you say is the MAIN reason why you have not been tested?
01 It's unlikely you've been exposed to HIV
02 You were afraid to find out if you were HIV positive (that you had HIV)
03 You didn't want to think about HIV or about being HIV positive
04 You were worried your name would be reported to the government if you tested positive
05 You didn't know where to get tested
06 You don't like needles
07 You were afraid of losing job, insurance, housing, friends, family, if people knew you were positive for AIDS infection
08 Some other reason
09 No particular reason
97 Refused
99 Don't know
UniverseText: Sample adults 18+ who have not been tested for HIV
SkipInstructions: <1-7,9,R,D> [goto EXTST12M]
<8> [goto WHYSPEC]
Question ID: ADS.055_00.000 Instrument Variable Name: WHYSPEC QuestionnaireFileName: Sample Adult
QuestionText: What was the main reason why you have not been tested?
7 Refused
9 Don't know
Verbatim Verbatim Response
UniverseText: Sample adults 18+ with some other reason for no HIV test
SkipInstructions: <20 char long> [goto EXTST12M]
Page 3 of 12
2007 NHIS Questionnaire - Sample Adult
AIDS Knowledge & Attitudes
Document Version Date: 12-Jul-06
Question ID: ADS.060_01.000 Instrument Variable Name: TST12M_M QuestionnaireFileName: Sample Adult
QuestionText: 1 of 2
[fill: Not including blood donations, in what month and year was your last test for HIV (the virus that causes AIDS)?/In
what month and year was your last test for HIV, (the virus that causes AIDS)?]
* Enter month of last HIV test.
* Enter "96" to go to the time period format.
01 January
02 February
03 March
04 April
05 May
06 June
07 July
08 August
09 September
10 October
11 November
12 December
96 Time period format
97 Refused
99 Don't know
UniverseText: Sample adults 18+ who have been tested for HIV/AIDS
SkipInstructions: <R,96> [goto TIMETST]
<1-12,D> [goto TST12M_Y]
Question ID: ADS.060_02.000 Instrument Variable Name: TST12M_Y QuestionnaireFileName: Sample Adult
QuestionText: 2 of 2
* Enter year of last HIV test.
1985-2006 1985-2006
9996 Time period format
9997 Refused
9999 Don't know
UniverseText: Sample adults 18+ who gave a month for their last HIV test or who didn't know the month
SkipInstructions: <1880-2030> [goto REATST]
<R,D> [goto TIMETST]
[if TST12M_M and TST12M_Y = a future date] goto ERR1_TST12M_Y
[if TST12M_M and TST12M_Y = a date prior to birth date] goto ERR2_TST12M_Y
Page 4 of 12
2007 NHIS Questionnaire - Sample Adult
AIDS Knowledge & Attitudes
Document Version Date: 12-Jul-06
Question ID: ADS.061_00.000 Instrument Variable Name: TIMETST QuestionnaireFileName: Sample Adult
QuestionText: Was it:
* Read answer categories.
1 6 months or less
2 More than 6 months but not more than 1 year ago
3 More than 1 year, but not more than 2 years ago
4 More than 2 years, but not more than 5 years ago
5 More than 5 years ago
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have been tested for HIV who refused or or requested the time period format at
TEST12M_M or refused or don't know the year of their last HIV test.
SkipInstructions: <1-5,R,D> [goto REATST]
Question ID: ADS.065_00.000 Instrument Variable Name: REATST QuestionnaireFileName: Sample Adult
QuestionText: (book) A15
I am going to show you a list of reasons why some people have been tested for HIV (the virus that causes AIDS).
[fill: Not including your blood donations, which of these would you say was the MAIN reason for your last HIV
test?/Which of these would you say was the MAIN reason for your last HIV test?]
01 Someone suggested you should be tested
02 You might have been exposed through sex or drug use
03 You might have been exposed through your work or at work
04 You just wanted to find out if you were infected or not
05 For part of a routine medical check-up, or for hospitalization or surgical procedure
06 You were sick or had a medical problem
07 You were pregnant or delivered a baby
08 For health or life insurance coverage
09 For military induction, separation, or military service
10 For immigration
11 For marriage license or to get married
12 You were concerned you could give HIV to someone
13 You wanted medical care or new treatments if you tested positive
14 Some other reason
15 No particular reason
97 Refused
99 Don't know
UniverseText: Sample adults 18+ who have been tested for HIV
SkipInstructions: <1>[goto REASWHO]
<2-13,15,R,D> [goto LASTST]
<14> [goto REASPEC]
Page 5 of 12
2007 NHIS Questionnaire - Sample Adult
AIDS Knowledge & Attitudes
Document Version Date: 12-Jul-06
Question ID: ADS.066_00.000 Instrument Variable Name: REASWHO QuestionnaireFileName: Sample Adult
QuestionText: Who suggested you should be tested - a doctor, nurse or other health care professional, a sex partner, someone at the health
department, or someone else?
1 Doctor, nurse or other health care professional
2 Sex partner
3 Someone at health department
4 Family member or friend
5 Other
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have been tested for HIV because someone suggested it
SkipInstructions: <1-4,R,D> [goto LASTST]
<5> [goto WHOSPEC]
Question ID: ADS.067_00.000 Instrument Variable Name: WHOSPEC QuestionnaireFileName: Sample Adult
QuestionText: Who suggested you should be tested?
7 Refused
9 Don’t know
Verbatim Verbatim Response
UniverseText: Sample adults 18+ who have been tested for HIV because someone not listed in REASWHO suggested it
SkipInstructions: <20 char long> [goto LASTST]
Question ID: ADS.069_00.000 Instrument Variable Name: REASPEC QuestionnaireFileName: Sample Adult
QuestionText: What was the main reason for your last HIV test?
7 Refused
9 Don't know
Verbatim Verbatim Response
UniverseText: Sample adults 18+ who have been tested for HIV for some reason not listed in REATST
SkipInstructions: <20 char long>[goto LASTST]
Page 6 of 12
2007 NHIS Questionnaire - Sample Adult
AIDS Knowledge & Attitudes
Document Version Date: 12-Jul-06
Question ID: ADS.070_00.000 Instrument Variable Name: LASTST QuestionnaireFileName: Sample Adult
QuestionText: (book) A16
[fill: Not including your blood donations, where did you have your last HIV test?/Where did you have your last HIV test?]
01 Private doctor/HMO
02 AIDS clinic/counseling/testing site
03 Hospital, emergency room, outpatient clinic
04 Other type of clinic
05 Public health department
06 At home
07 Drug treatment facility
08 Military induction or military service site
09 Immigration site
10 In a correctional facility (jail or prison)
11 Other location
97 Refused
99 Don't know
UniverseText: Sample adults 18+ who have been tested for HIV
SkipInstructions: <1-3,5,7-10,R,D> [goto GIVNAM]
<4> [goto CLINTYP]
<6> [goto WHOADM]
<11> [goto LASTSPEC]
Question ID: ADS.072_00.000 Instrument Variable Name: CLINTYP QuestionnaireFileName: Sample Adult
QuestionText: What type of clinic did you go to for your last HIV test?
01 Family planning clinic
02 Prenatal clinic
03 Tuberculosis clinic
04 STD clinic
05 Community health clinic
06 Clinic run by employer or insurance company
07 Other
97 Refused
99 Don't know
UniverseText: Sample adults 18+ who have been tested for HIV at an other type of clinic
SkipInstructions: <1-7,R,D> [goto GIVNAM]
Page 7 of 12
2007 NHIS Questionnaire - Sample Adult
AIDS Knowledge & Attitudes
Document Version Date: 12-Jul-06
Question ID: ADS.074_00.000 Instrument Variable Name: WHOADM QuestionnaireFileName: Sample Adult
QuestionText: Was this test administered by a nurse or other health worker, or did you use a self-sampling kit?
1 Nurse or health worker
2 Self-sampling kit
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have been tested for HIV at home
SkipInstructions: <1,2,R,D> [goto GIVNAM]
Question ID: ADS.076_00.000 Instrument Variable Name: LASTSPEC QuestionnaireFileName: Sample Adult
QuestionText: Where did you have your last HIV test?
* This should be a specific location that is not on the list.
7 Refused
9 Don't know
Verbatim Verbatim Response
UniverseText: Sample adults 18+ who were tested at an other location
SkipInstructions: <20 char long> [goto GIVNAM]
Question ID: ADS.080_00.000 Instrument Variable Name: GIVNAM QuestionnaireFileName: Sample Adult
QuestionText: The last time you were tested, did you have to give your first and last names?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have been tested for HIV
SkipInstructions: <1,2,R,D> [goto EXTST12M]
Question ID: ADS.110_00.000 Instrument Variable Name: EXTST12M QuestionnaireFileName: Sample Adult
QuestionText: [fill: Do you expect to have another test for HIV in the next 12 months, not including blood donations?/Do you expect to
have a test for HIV in the next 12 months, not including blood donations?]
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D> [goto CHNSADS]
Page 8 of 12
2007 NHIS Questionnaire - Sample Adult
AIDS Knowledge & Attitudes
Document Version Date: 12-Jul-06
Question ID: ADS.140_00.000 Instrument Variable Name: CHNSADS QuestionnaireFileName: Sample Adult
QuestionText: What are your chances of GETTING HIV (the virus that causes AIDS)?
Would you say high, medium, low, or none?
1 High
2 Medium
3 Low
4 None
5 Already have HIV or AIDS
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1-5,R,D> [goto STMTRU]
Question ID: ADS.150_00.000 Instrument Variable Name: STMTRU QuestionnaireFileName: Sample Adult
QuestionText: (book) A17
Tell me if ANY of these statements is true for YOU. Do NOT tell me WHICH Statement or statements are true for you.
Just IF ANY of them are.
* Read if necessary.
(a) You have hemophilia and have received clotting factor concentrations.
(b) You are a man who has had sex with other men, even just one time.
(c ) You have taken street drugs by needle, even just one time.
(d) You have traded sex for money or drugs, even just one time.
(e) You have tested positive for HIV (the virus that causes AIDS).
(f) You have had sex (even just one time) with someone who would answer "yes" to any of these statements.
1 Yes, at least one statement is true
2 No, none of these statements are true
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D> [If AGE GE <50> [go to TBHRD] else [go to STD]]
Page 9 of 12
2007 NHIS Questionnaire - Sample Adult
AIDS Knowledge & Attitudes
Document Version Date: 12-Jul-06
Question ID: ADS.160_00.000 Instrument Variable Name: STD QuestionnaireFileName: Sample Adult
QuestionText: The next questions are about other sexually transmitted diseases or STDs. STDs are also known as venereal diseases or
VD. Examples of STDs are gonorrhea, chlamydia (CLUH-MIH-DEE-UH), syphilis, herpes, and genital warts.
In the past five years, have you had an STD other than HIV or AIDS?
* If asked, tell respondent to include newly contracted STDs and recurring flare-ups of previously contracted STDs.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18-49
SkipInstructions: <1> [goto STDDOC]
<2,R,D> [goto TBHRD]
Question ID: ADS.170_00.000 Instrument Variable Name: STDDOC QuestionnaireFileName: Sample Adult
QuestionText: The last time you had an STD other than HIV or AIDS, did you see a doctor or other health professional to get it checked?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18 - 49 who have had an STD other than HIV or AIDS in the past 5 years
SkipInstructions: <1> [goto STDWHER]
<2,R,D> [goto TBHRD]
Question ID: ADS.180_00.000 Instrument Variable Name: STDWHER QuestionnaireFileName: Sample Adult
QuestionText: Where did you go to be checked?
* Read answer choices only if necessary.
1 Private doctor
2 Family planning clinic
3 STD clinic
4 Emergency room
5 Health department
6 Some other place
7 Refused
9 Don't know
UniverseText: Sample adults 18-49 who have had an STD other than HIV or AIDS who saw a doctor or other health professional
SkipInstructions: <1-5,R,D> [goto TBHRD]
<6> [goto STDWOTH]
Page 10 of 12
2007 NHIS Questionnaire - Sample Adult
AIDS Knowledge & Attitudes
Document Version Date: 12-Jul-06
Question ID: ADS.190_00.000 Instrument Variable Name: STDWOTH QuestionnaireFileName: Sample Adult
QuestionText: Where did you go to be checked?
7 Refused
9 Don't know
Verbatim Verbatim Response
UniverseText: Sample adults 18-49 who have had an STD other than HIV or AIDS who were tested at some other place
SkipInstructions: <20 char long> [goto TBHRD]
Question ID: ADS.200_00.000 Instrument Variable Name: TBHRD QuestionnaireFileName: Sample Adult
QuestionText: The next questions are about tuberculosis, or TB.
Have you ever heard of tuberculosis?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto TBKNOW]
<2,R,D> [goto HOMELESS]
Question ID: ADS.210_00.000 Instrument Variable Name: TBKNOW QuestionnaireFileName: Sample Adult
QuestionText: Have you ever personally known anyone who had TB?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have heard of tuberculosis
SkipInstructions: <1,2,R,D> [goto TB]
Page 11 of 12
2007 NHIS Questionnaire - Sample Adult
AIDS Knowledge & Attitudes
Document Version Date: 12-Jul-06
Question ID: ADS.220_00.000 Instrument Variable Name: TB QuestionnaireFileName: Sample Adult
QuestionText: How much do you know about TB - a lot, some, a little, or nothing?
1 A lot
2 Some
3 A little
4 Nothing
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have heard of tuberculosis
SkipInstructions: <1-3> [goto TBSPRD]
<4> [goto TBCHANC]
<R,D> [goto HOMELESS]
Question ID: ADS.230_00.000 Instrument Variable Name: TBSPRD QuestionnaireFileName: Sample Adult
QuestionText: (book) A18
How is TB spread?
* Probe: Can TB be spread in any other way?
* Mark all that apply, separate with commas.
1 Breathing the air around a person who is sick with TB
2 Sharing eating/drinking utensils
3 Through semen or vaginal secretions shared during sexual intercourse
4 From smoking
5 From mosquito or other insect bites
6 Other
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have knowledge of tuberculosis
SkipInstructions: <1-6,R,D> goto TBCURED
Question ID: ADS.240_00.000 Instrument Variable Name: TBCURED QuestionnaireFileName: Sample Adult
QuestionText: As far as you know, can TB be cured?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have knowledge of tuberculosis
SkipInstructions: <1,2,R,D> [goto TBCHANC]
Page 12 of 12
2007 NHIS Questionnaire - Sample Adult
AIDS Knowledge & Attitudes
Document Version Date: 12-Jul-06
Question ID: ADS.250_00.000 Instrument Variable Name: TBCHANC QuestionnaireFileName: Sample Adult
QuestionText: What are your chances of getting TB? Would you say high, medium, low, or none?
1 High
2 Medium
3 Low
4 None
5 Already have TB
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have knowledge or heard of tuberculosis or know nothing about tuberculosis
SkipInstructions: <1-5,R,D> [goto TBSHAME]
Question ID: ADS.260_00.000 Instrument Variable Name: TBSHAME QuestionnaireFileName: Sample Adult
QuestionText: (Fill1: If a member of your family were diagnosed with TB, would you feel ashamed or embarrassed?)
(Fill2: If you or a member of your family were diagnosed with TB, would you feel ashamed or embarrassed?)
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have knowledge or heard of tuberculosis or know nothing about tuberculosis
SkipInstructions: <1,2,R,D> [goto HOMELESS]
Question ID: ADS.270_00.000 Instrument Variable Name: HOMELESS QuestionnaireFileName: Sample Adult
QuestionText: Have you ever spent more than 24 hours living on the streets, in a shelter, or in a jail or prison?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D> [goto next section]
| File Type | application/msword |
| Author | Howard Riddick |
| Last Modified By | Howard Riddick |
| File Modified | 2006-09-29 |
| File Created | 2006-09-29 |