ATTACHMENT 1
H
OMB
No. (0925-xxxx), Expiration Date (xx/xx/xxxx)
SECTION A - STUDY DATA
A1. Subject ID
__ __ __ __ __ __ __ __
A2. Subject Type (Choose one)
__ Case Skip to A4
__ Control
A3. What type of control is this study subject - recruited onsite or returning donor? (Choose one)
1 Group A Control - Recruited onsite at time of donation
2 Group B Control - Recruited offsite by telephone or mail
7 Don't Know
8 Refuse to Answer
9 Not Applicable
A4. Blood collection site (Choose one)
1 FPS - Sao Paulo
2 HEMOMINAS - Minas Gerais
3 HEMOPE - Pernambuco
4 HEMORIO-Rio de Janeiro
A5. Month of interview (Choose one)
01 January
02 February
03 March
04 April
05 May
06 June
07 July
08 August
09 September
10 October
11 November
12 December
A6. Year of interview (please enter four numbers)
__ __ __ __ yyyy
A7. Research Assistant Initials: __ __ __ __ __
A8a. Place of Interview (Choose one)
1 Blood Center
2 Study Subject's Home
3 Study Subject's Work
4 Other
If A8a is not equal to 4, then skip to A9.
A8b. Please specify other place of interview
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
A9. Study subject is able to read (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
A10. What level of education do you have? (Choose one)
00 Never been to school
01 Elementary school
02 High school
03 College or technical school
04 Graduate school or professional degree
97 Don't Know
98 Refuse to Answer
A11. What is your occupation?
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
A12. Type of interview (Choose one)
1 CASI
2 ACASI
3 Paper
SECTION B - DEMOGRAPHIC DATA
We are asking you to respond as truthfully as you can. The answers are anonymous. Your answers will be reported together with all other people who complete this questionnaire. In this section of the questionnaire the research assistant will show you how to use the computer to answer the interview questions. After completing this section, with help from the research assistant, you will be left to complete the interview in private. If you have any questions at anytime or are confused, please ask for help.
B1. What is your gender?
1 Male
2 Female
7 Don't Know
8 Refuse to Answer
9 Not Applicable
B2. What is your birth year?
__ __ __ __
9997 Don't Know
9998 Refuse to Answer
B3. What is your birth month? (Choose one)
__ __ January
__ __ February
__ __ March
__ __ April
__ __ May
__ __ June
__ __ July
__ __ August
__ __ September
__ __ October
__ __ November
__ __ December
__ __ Don't Know
__ __ Refuse to Answer
__ __ Not Applicable
B4. What is your birth day?
__ __
97 Don't Know
98 Refuse to Answer
B5a. What is your country of birth? (Choose one)
1 Brazil
2 Other
7 Don't Know
8 Refuse to Answer
If B5a is not equal to 2, then skip to B6.
B5b. Please specify your country of birth
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
B6. What is your ethnicity? (Choose one)
1 Caucasian (white)
2 Black
3 Asian or yellow (yellow)
4 Mulatto (brown)
5 Indian (indigenous)
6 Other
7 Don't Know
8 Refuse to Answer
B7. What is your current marital status? (Choose one)
1 Single, never married
2 Living together but not legally married
3 Married
4 Separated/ divorced
5 Widowed
7 Don't Know
8 Refuse to Answer
If B7 is not equal to 2 and B7 is not equal to 3, then skip to C1.
B8. If you are married or living with someone, is your spouse/cohabitating partner
1 Male
2 Female
7 Don't Know
8 Refuse to Answer
9 Not Applicable
Section C - Previous donation and HIV testing
C1. Have you ever donated blood at another blood center? (Choose one)
0 No Skip to C4
1 Yes
7 Don't Know
8 Refuse to Answer
C2. How many times have you donated blood at another blood center? (Choose one)
1 1 time
2 2 or more times
7 Don't Know
8 Refuse to Answer
C3. At the time of your last donation, do you remember being given information about who should not donate blood? (Check all that apply)
__ No.
__ Yes, written information (pamphlets).
__ Yes, through discussion with the health historian/physician at the blood bank
__ Don't Know
__ Refuse to Answer
__ Not Applicable
C4. Other than blood donation, have you ever been tested for HIV? (Choose one)
0 No Skip to instruction before D1
1 Yes
7 Don't Know
8 Refuse to Answer
C5a. What was the reason for the HIV test? (Choose one)
1 Pregnancy care
2 Health insurance
3 Physician's order, routine medical care, hospitalization or surgery
4 I wanted to know my HIV status
5 Other
7 Don't Know
8 Refuse to Answer
If C5a is not equal to 5, then skip to C6a.
C5b. Please specify the other reason for test
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
C6a. Other than a blood center, where else have you been tested for HIV? (Choose one)
1 Private lab
2 Health department
3 Hospital
4 Public lab
5 Other test site
7 Don't Know
8 Refuse to Answer
If C6a is not equal to 5, then skip to C7.
C6b. Please specify the other test site.
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
C7. Excluding HIV testing conducted as part of blood donation, how many times have you been tested for HIV? (Choose one)
0 Never
1 1 time
2 2 or more times
7 Don't Know
8 Refuse to Answer
Section D - Incentives and Motivations for Donating
The following questions will ask you about things that you may do in your daily life.
D1. Have you helped carry a stranger's belongings? (Choose one) 0 No
1 Yes
7 Don't Know
8 Refuse to Answer
D2. Do you allow someone who is elderly or disabled to go ahead of you in a line? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
D3. Have you offered to help a handicap or elderly person across a street? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
D4. Do you give money to charity? (Choose one) 0 No
1 Yes
7 Don't Know
8 Refuse to Answer
The following questions will ask you about factors that may have influenced your decision to donate blood. Use the following scale to indicate how much the factors contributed to your decision to donate blood today. 1- Not at all, 2 - Very little, 3 - Somewhat, 4 - Very much
D5a. To anonymously help someone else who needs blood (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
7 Don't Know
8 Refuse to Answer
D5b. To help a friend or relative who is sick or needs blood (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
7 Don't Know
8 Refuse to Answer
D5c. In response to a campaign on TV or radio (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
7 Don't Know
8 Refuse to Answer
D5d. I received a telephone call or letter from the blood bank asking me to donate (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
7 Don't Know
8 Refuse to Answer
D5e. I think that it is important to give blood (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
7 Don't Know
8 Refuse to Answer
D5f. I wanted to get test results for my blood (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
7 Don't Know
8 Refuse to Answer
D5g. My blood type is in high demand (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
7 Don't Know
8 Refuse to Answer
D5h. I think that I am doing something important for society (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
7 Don't Know
8 Refuse to Answer
D5i. I may need blood myself someday (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
7 Don't Know
8 Refuse to Answer
D5j. I heard that blood donation is good for my health (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
7 Don't Know
8 Refuse to Answer
D5k. I like to know about my health and blood donation is a good way to find out (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
7 Don't Know
8 Refuse to Answer
D5l. Someone offered me money for donating (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
7 Don't Know
8 Refuse to Answer
D5m. Blood banks always need blood and so donating is the right thing to do. (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
7 Don't Know
8 Refuse to Answer
D5n. Is there another reason that best explains why you came to donate (Choose one)
0 No Skip to D6
1 Yes
7 Don't Know Skip to D6
8 Refuse to Answer Skip to D6
D5p. What is the reason that best explains why you came to donate
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
D6. Some people feel they must donate blood because family, friends, co-workers or other persons in an organization they know donate blood or encourage others to donate. Did this happen to you when you last donated blood? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
D7. Do you believe that the blood center uses better HIV tests than are available at other places? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
D8. Did you donate blood because you wanted to be tested for HIV? (Choose one)
0 No Skip to D10
1 Yes
7 Don't Know
8 Refuse to Answer
D9a. Please check all the boxes for the factors that contributed to your decision to come to the blood center to be tested for HIV. When you have selected all of your answers, please touch the "Next Question" box. (Check all that apply)
__ Only place I know of offering HIV testing
__ Testing is free
__ Testing is confidential
__ Testing is more accurate than at other sites
__ Testing is more convenient than at other test sites
__ Other reason
__ Don't Know
__ Refuse to Answer
If D9aF is equal to 0, then skip to D10.
D9b. Please specify other reason
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
D10. Did you donate blood because you wanted to be tested for hepatitis? (Choose one)
0 No Skip to D12a
1 Yes
7 Don't Know
8 Refuse to Answer
D11a. Please check all the boxes for the factors that contributed to your decision to come to the blood center to be tested for hepatitis. When you have selected all of your answers, please touch the "Next Question" box. (Check all that apply)
__ Only place I know of offering Hepatitis testing
__ Testing is free
__ Testing is confidential
__ Testing is more accurate than at other sites
__ Testing is more convenient than at other sites
__ Other reason
__ Don't Know
__ Refuse to Answer
If D11aF is equal to 0, then skip to D12a.
D11b. Please specify other reason
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
D12a. Did you come to the blood center to be tested for some other reason? (Choose one)
0 No Skip to D13
1 Yes
7 Don't Know
8 Refuse to Answer
D12b. Please specify other reason
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
D13. Did a health worker such as a doctor, nurse, or someone from a health department suggest that you go to the blood center for a blood test for HIV, hepatitis, or for some other reason? (Choose one)
0 No Skip to instruction before D15
1 Yes
7 Don't Know
8 Refuse to Answer
D14. Please tell us who suggested you to come to the blood center (Choose one)
1 Doctor
2 Nurse
3 Someone from the health department
4 Other
7 Don't Know
8 Refuse to Answer
Now we will ask a few questions about what you think about HIV risks and donating:
D15. You can donate blood if you have engaged in risk behaviors for HIV or AIDS because the blood center tests all blood and throws away any infected blood (Choose one)
1 True
2 False
7 Don't Know
8 Refuse to Answer
D16. You can donate blood even if you engage in risk behaviors for HIV or AIDS as long as you have a negative HIV test. (Choose one)
1 True
2 False
7 Don't Know
8 Refuse to Answer
D17. The blood test for HIV identifies everyone who is infected with the virus (Choose one)
1 True
2 False
7 Don't Know
8 Refuse to Answer
Section E - Sexual History
Now, we want to ask about the people you have had sex with and your sexual partners. We understand that these questions are about intimate and private matters, which could make you uncomfortable. Please keep in mind that the questions are part of a scientific study, and the researchers will make every effort to keep your responses confidential to the extent allowed by law. However, there is a small chance that your responses may not be kept confidential, but your name is not collected on the questionnaire and your responses cannot be easily traced back to you. Please answer these questions to the best of your knowledge and as truthfully as you can.
E1. What do you consider yourself to be? (Choose one)
1 Straight/ heterosexual
2 Bisexual
3 Gay/ homosexual
7 Don't Know
8 Refuse to Answer
The following questions will ask you about your sexual experiences. In these questions, include only those people you have had oral, vaginal, or anal sex with. Do not include people that you have just kissed. Please note: When evaluating whether you have engaged in each sexual activity, consider activities both WITH and WITHOUT EJACULATION.
E2. (Ask of Men Only) How many different women have you had sex with since you first began having sex?
__ __ __ __
9997 Don't Know
9998 Refuse to Answer
9999 Not Applicable
E3. (Ask of Men Only) How many different men have you had sex with since you first began having sex?
__ __
97 Don't Know
98 Refuse to Answer
99 Not Applicable
E2. (Ask of Women Only) How many different men have you had sex with since you first began having sex?
__ __ __ __
9997 Don't Know
9998 Refuse to Answer
9999 Not Applicable
Section F - Sexual partners risks
Now, we want to ask about the people you have had sex with or your sexual partners. Specifically, we want to ask you about some of their risks for HIV. Please answer these questions to the best of your knowledge.
F1a. To the best of your knowledge, have you ever had sex with anyone who was an intravenous drug user? (Choose one)
0 No Skip to F2a
1 Yes
7 Don't Know
8 Refuse to Answer
F1b. In the year before your last donation, have you had sex with anyone who was an intravenous drug user? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
F2a. To the best of your knowledge, have you ever had sex with anyone who tested positive for HIV? (Choose one)
0 No Skip to F3a
1 Yes
7 Don't Know
8 Refuse to Answer
F2b. In the year before your last donation, have you had sex with anyone who tested positive for HIV? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
F3a. To the best of your knowledge, if your partner tested positive for HIV, was he/she taking HIV medications? (Choose one)
0 No Skip to F4a
1 Yes
7 Don't Know
8 Refuse to Answer
F3b. In the year before your last donation, if your partner tested positive for HIV, was he/she taking HIV medications? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
F4a. To the best of your knowledge, have you ever had sex with a man who has had sex with another man? (Choose one)
0 No Skip to F5a
1 Yes
7 Don't Know
8 Refuse to Answer
F4b. In the year before your last donation, have you had sex with a man who has had sex with another man? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
F5a. To the best of your knowledge, have you ever had sex with anyone who received a blood transfusion? (Choose one)
0 No Skip to F6a
1 Yes
7 Don't Know
8 Refuse to Answer
F5b. In the year before your last donation, have you had sex with anyone who received blood transfusion? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
F6a. To the best of your knowledge, have you ever had sex with anyone who was a hemophiliac? (Choose one)
0 No Skip to F7a
1 Sim
7 Don't Know
8 Refuse to Answer
F6b. In the year before your last donation, have you had sex with anyone who was a hemophiliac? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
F7a. To the best of your knowledge, have you ever had sex with anyone who has spent three or more nights in jail, prison, or a detention center? (Choose one)
0 No Skip to F8a
1 Yes
7 Don't Know
8 Refuse to Answer
F7b. In the year before your last donation, have you had sex with anyone who has spent three or more nights in jail, prison, or a detention center? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
F8a. To the best of your knowledge, have you ever had sex with anyone who had a job that involved exposure to blood or other body fluids? (Choose one)
0 No Skip to instruction before G1
1 Yes
7 Don't Know
8 Refuse to Answer
F8b. In the year before your last donation, have you had sex with anyone who had a job that involved exposure to blood or other body fluids? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
Section G - Social Matrix
This next set of questions is about sexual experiences you may have had. While some people have had a lot of sexual experience, others have not, so questions may or may not apply to you. Please answer these questions as accurately as possible. Remember that answers that you provide will be combined with those from all other people who complete the questionnaire and we will never disclose individual responses to any question. Specifically, we will ask about sexual activities that include vaginal and or anal intercourse. Please answer these questions to the best of your knowledge and as truthfully as you can.
G1. How many people did you have sex with in the 12 months before your blood donation?
__ __
97 Don't Know
98 Refuse to Answer
99 Not Applicable
If G1 is equal to 0, then skip to instruction before H1.
Now we're going to ask you specific questions about your sex partners. If you had more than five partners in the 12 months before your last blood donation, we are only going to ask you about the five most recent sex partners or contacts that you had before your last blood donation. Please start with the most recent sex partner or contact that you had before your blood donation and then move back in time. Please be sure to focus on the sex partners you had before your last blood donation and not partners that you may have had after your last blood donation. When you answer the questions keep in mind we are asking about your partners before your last blood donation.
G2. What is Partner 1's gender?
1 Male
2 Female
7 Don't Know
8 Refuse to Answer
9 Not Applicable
G3. How old is partner 1?
__ __
97 Don't Know
98 Refuse to Answer
G4. What type of partner is partner 1? (Choose one)
1 Anonymous - Did not know, met for sex, never plan to see again
2 One time - Already knew person, but had sex only once
3 Acquaintance - Had sex more than once but not regularly
4 Friend (you socialize with this person) - Had sex more than once but not regularly
5 Main partner - Your spouse or main sex partner
6 Sex worker - Money or other goods were exchanged for sex
7 Don't Know
8 Refuse to Answer
G5. How would you describe partner 1's race or ethnicity? (Choose one)
1 Caucasian
2 Black
3 Asian or yellow
4 Mulatto
5 Indian
7 Don't Know
8 Refuse to Answer
G6. Is partner 1 an injection drug user? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
If G2 is equal to 2 or G2 is equal to 4, then skip to G8.
G7. Is partner 1 a male who has had sex with other males? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
G8. What is partner 1's HIV status? (Choose one)
1 Positive
2 Negative
3 Unknown
7 Don't Know
8 Refuse to Answer
G9. Where did you first meet partner 1? (Choose one)
01 Bar, cafe, nightclub, restaurant, gym or athletic activity
02 Sex club, bathhouse
03 Street, park, library, public transportation
04 Parties, clubs, political function or church
05 Internet
06 Dating service, newspaper ads
07 Carnival
08 Met some other way
09 Work
98 Refuse to Answer
If G9 is not equal to 8, then skip to instruction before G11.
G10. Specify where you met partner 1:
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
If B1 is equal to 1 and G2 is equal to 1, then skip to G15.
If B1 is equal to 1 and G2 is equal to 2, then skip to G11.
If B1 is equal to 2 and G2 is equal to 1, then skip to G11.
If B1 is equal to 2 and G2 is equal to 2, then skip to instruction before G19.
G11. Number of times you had vaginal intercourse with partner 1 in past 12 months. (Choose one)
__ none
__ 1 to 3 times
__ 4 to 10 times
__ more than 10 times
__ Don't Know
__ Refuse to Answer
If G11 is equal to 0, then skip to G13.
G12. When you had vaginal sex, how frequently did you use condoms? (Choose one)
__ never
__ sometimes
__ every time
__ Don't Know
__ Refuse to Answer
G13. Number of times you had anal intercourse with partner 1 in past 12 months. (Choose one)
__ none
__ 1 to 3 times
__ 4 to 10 times
__ more than 10 times
__ Don't Know
__ Refuse to Answer
If G13 is equal to 0, then skip to instruction before G19.
G14. When you had anal sex, how frequently did you use condoms? (Choose one)
__ never
__ sometimes
__ every time
__ Don't Know
__ Refuse to Answer
Skip to instruction before G19.
G15. Number of times you had insertive anal intercourse with partner 1 in past 12 months. (Choose one)
__ none
__ 1 to 3 times
__ 4 to 10 times
__ more than 10 times
__ Don't Know
__ Refuse to Answer
If G15 is equal to 0, then skip to G17.
G16. When you had insertive anal sex, how frequently did you use condoms? (Choose one)
__ never
__ some times
__ every time
__ Don't Know
__ Refuse to Answer
If G16 is equal to 0, then skip to G17.
G17. Number of times you had receptive anal intercourse with partner 1 in past 12 months. (Choose one)
__ none
__ 1 to 3 times
__ 4 to 10 times
__ more than 10 times
__ Don't Know
__ Refuse to Answer
If G17 is equal to 0, then skip to instruction before G19.
G18. When you had receptive anal sex, how frequently did you use condoms? (Choose one)
__ never
__ some times
__ every times
__ Don't Know
__ Refuse to Answer
If G18 is equal to 0, then skip to instruction before G19.
If G1 is equal to 1, then skip to instruction before H1.
The next set of questions is about your second sexual partner, BEFORE your last blood donation.
G19. What is Partner 2's gender?
1 Male
2 Female
7 Don't Know
8 Refuse to Answer
9 Not Applicable
G20. How old is partner 2?
__ __
97 Don't Know
98 Refuse to Answer
G21. What type of partner is partner 2? (Choose one)
1 Anonymous - Did not know, met for sex, never plan to see again
2 One time - Already knew person, but had sex only once
3 Acquaintance - Had sex more than once but not regularly
4 Friend (you socialize with this person) - Had sex more than once but not regularly
5 Main partner - Your spouse or main sex partner
6 Sex worker - Money or other goods were exchanged for sex
7 Don't Know
8 Refuse to Answer
G22. How would you describe partner 2's race or ethnicity? (Choose one)
1 Caucasian
2 Black
3 Asian or yellow
4 Mulatto
5 Indian
7 Don't Know
8 Refuse to Answer
G23. Is partner 2 an injection drug user? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
If G19 is equal to 2 or G19 is equal to 4, then skip to G25.
G24. Is partner 2 a male who has had sex with other males? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
G25. What is partner 2's HIV status? (Choose one)
1 Positive
2 Negative
3 Unknown
7 Don't Know
8 Refuse to Answer
G26. Where did you first meet partner 2? (Choose one)
01 Bar, cafe, nightclub, restaurant, gym or athletic activity
02 Sex club, bathhouse
03 Street, park, library, public transportation
04 Parties, clubs, political function or church
05 Internet
06 Dating service, newspaper ads
07 Carnival
08 Met some other way
09 Work
98 Refuse to Answer
If G26 is not equal to 8, then skip to instruction before G28.
G27. Specify where you met partner 2:
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
If B1 is equal to 1 and G19 is equal to 1, then skip to G32.
If B1 is equal to 1 and G19 is equal to 2, then skip to G28.
If B1 is equal to 2 and G19 is equal to 1, then skip to G28.
If B1 is equal to 2 and G19 is equal to 2, then skip to instruction before G36.
G28. Number of times you had vaginal intercourse with partner 2 in past 12 months. (Choose one)
__ none
__ 1 to 3 times.
__ 4 to 10 times.
__ more than 10 times.
__ Don't Know
__ Refuse to Answer
If G28 is equal to 0, then skip to G30.
G29. When you had vaginal sex, how frequently did you use condoms? (Choose one)
__ Never
__ Sometimes
__ Every time
__ Don't Know
__ Refuse to Answer
If G29 is equal to 0, then skip to G30.
G30. Number of times you had anal intercourse with partner 1 in past 12 months. (Choose one)
__ none
__ 1 to 3 times
__ 4 to 10 times
__ more than 10 times
__ Don't Know
__ Refuse to Answer
If G30 is equal to 0, then skip to instruction before G36.
G31. When you had anal sex, how frequently did you use condoms? (Choose one)
__ never
__ sometimes
__ every time
__ Don't Know
__ Refuse to Answer
Skip to instruction before G36.
G32. Number of times you had insertive anal intercourse with partner 2 in past 12 months. (Choose one)
__ none
__ 1 to 3 times
__ 4 to 10 times
__ more than 10 times
__ Don't Know
__ Refuse to Answer
If G32 is equal to 0, then skip to G34.
G33. When you had insertive anal sex, how frequently did you use condoms? (Choose one)
__ never
__ some times
__ every time
__ Don't Know
__ Refuse to Answer
If G33 is equal to 0, then skip to G34.
G34. Number of times you had receptive anal intercourse with partner 2 in past 12 months. (Choose one)
__ none
__ 1 to 3 times
__ 4 to 10 times
__ more than 10 times
__ Don't Know
__ Refuse to Answer
If G34 is equal to 0, then skip to instruction before G36.
G35. When you had receptive anal sex, how frequently did you use condoms? (Choose one)
__ never
__ some times
__ every times
__ Don't Know
__ Refuse to Answer
If G35 is equal to 0, then skip to instruction before G36.
If G1 is equal to 2, then skip to instruction before H1.
The next set of questions is about your third sexual partner, BEFORE your last blood donation.
G36. What is Partner 3's gender?
1 Male
2 Female
7 Don't Know
8 Refuse to Answer
9 Not Applicable
G37. How old is partner 3?
__ __
97 Don't Know
98 Refuse to Answer
G38. What type of partner is partner 3? (Choose one)
1 Anonymous - Did not know, met for sex, never plan to see again
2 One time - Already knew person, but had sex only once
3 Acquaintance - Had sex more than once but not regularly
4 Friend (you socialize with this person) - Had sex more than once but not regularly
5 Main partner - Your spouse or main sex partner
6 Sex worker - Money or other goods were exchanged for sex
7 Don't Know
8 Refuse to Answer
G39. How would you describe partner 3's race or ethnicity? (Choose one)
1 Caucasian
2 Black
3 Asian or yellow
4 Mulatto
5 Indian
7 Don't Know
8 Refuse to Answer
G40. Is partner 3 an injection drug user? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
If G36 is equal to 2 or G36 is equal to 4, then skip to G42.
G41. Is partner 3 a male who has had sex with other males? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
G42. What is partner 3's HIV status? (Choose one)
1 Positive
2 Negative
3 Unknown
7 Don't Know
8 Refuse to Answer
G43. Where did you first meet partner 3? (Choose one)
01 Bar, cafe, nightclub, restaurant, gym or athletic activity.
02 Sex club, bathhouse
03 Street, park, library, public transportation
04 Parties, clubs, political function or church
05 Internet
06 Dating service, newspaper ads
07 Carnival
08 Met some other way
09 Work
98 Refuse to Answer
If G43 is not equal to 8, then skip to instruction before G45.
G44. Specify where you met partner 3:
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
If B1 is equal to 1 and G36 is equal to 1, then skip to G49.
If B1 is equal to 1 and G36 is equal to 2, then skip to G45.
If B1 is equal to 2 and G36 is equal to 1, then skip to G45.
If B1 is equal to 2 and G36 is equal to 2, then skip to instruction before G53.
G45. Number of times you had vaginal intercourse with partner 3 in past 12 months. (Choose one)
__ none
__ 1 to 3 times.
__ 4 to 10 times.
__ more than 10 times.
__ Don't Know
__ Refuse to Answer
If G45 is equal to 0, then skip to G47.
G46. When you had vaginal sex, how frequently did you use condoms? (Choose one)
__ Never
__ Sometimes.
__ Every time.
__ Don't Know
__ Refuse to Answer
G47. Number of times you had anal intercourse with partner 3 in past 12 months. (Choose one)
__ none
__ 1 to 3 times
__ 4 to 10 times
__ more than 10 times
__ Don't Know
__ Refuse to Answer
If G47 is equal to 0, then skip to instruction before G53.
G48. When you had anal sex, how frequently did you use condoms? (Choose one)
__ never
__ sometimes
__ every time
__ Don't Know
__ Refuse to Answer
Skip to instruction before G53.
G49. Number of times you had insertive anal intercourse with partner 3 in past 12 months. (Choose one)
__ none
__ 1 to 3 times
__ 4 to 10 times
__ more than 10 times
__ Don't Know
__ Refuse to Answer
If G49 is equal to 0, then skip to G51.
G50. When you had insertive anal sex, how frequently did you use condoms? (Choose one)
__ never
__ some times
__ every time
__ Don't Know
__ Refuse to Answer
If G50 is equal to 0, then skip to G51.
G51. Number of times you had receptive anal intercourse with partner 3 in past 12 months. (Choose one)
__ none
__ 1 to 3 times
__ 4 to 10 times
__ more than 10 times
__ Don't Know
__ Refuse to Answer
If G51 is equal to 0, then skip to instruction before G53.
G52. When you had receptive anal sex, how frequently did you use condoms? (Choose one)
__ never
__ some times
__ every times
__ Don't Know
__ Refuse to Answer
If G52 is equal to 0, then skip to instruction before G53.
If G1 is equal to 3, then skip to instruction before H1.
The next set of questions is about your fourth sexual partner, BEFORE your last blood donation.
G53. What is Partner 4's gender?
1 Male
2 Female
7 Don't Know
8 Refuse to Answer
9 Not Applicable
G54. How old is partner 4?
__ __
97 Don't Know
98 Refuse to Answer
G55. What type of partner is partner 4? (Choose one)
1 Anonymous - Did not know, met for sex, never plan to see again
2 One time - Already knew person, but had sex only once
3 Acquaintance - Had sex more than once but not regularly
4 Friend (you socialize with this person) - Had sex more than once but not regularly
5 Main partner - Your spouse or main sex partner
6 Sex worker - Money or other goods were exchanged for sex
7 Don't Know
8 Refuse to Answer
G56. How would you describe partner 4's race or ethnicity? (Choose one)
1 Caucasian
2 Black
3 Asian or yellow
4 Mulatto
5 Indian
7 Don't Know
8 Refuse to Answer
G57. Is partner 4 an injection drug user? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
If G53 is equal to 2 or G53 is equal to 4, then skip to G59.
G58. Is partner 4 a male who has had sex with other male? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
G59. What is partner 4's HIV status? (Choose one)
1 Positive
2 Negative
3 Unknown
7 Don't Know
8 Refuse to Answer
G60. Where did you first meet partner 4? (Choose one)
01 Bar, cafe, nightclub, restaurant, gym or athletic activity.
02 Sex club, bathhouse
03 Street, park, library, public transportation
04 Parties, clubs, political function or church
05 Internet
06 Dating service, newspaper ads
07 Carnival
08 Met some other way
09 Work
98 Refuse to Answer
If G60 is not equal to 8, then skip to instruction before G62.
G61. Specify where you met partner 4:
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
If B1 is equal to 1 and G53 is equal to 1, then skip to G66.
If B1 is equal to 1 and G53 is equal to 2, then skip to G62.
If B1 is equal to 2 and G53 is equal to 1, then skip to G62.
If B1 is equal to 2 and G53 is equal to 2, then skip to instruction before G70.
G62. Number of times you had vaginal intercourse with partner 4 in past 12 months. (Choose one)
__ none
__ 1 to 3 times.
__ 4 to 10 times.
__ more than 10 times.
__ Don't Know
__ Refuse to Answer
If G62 is equal to 0, then skip to G64.
G63. When you had vaginal sex, how frequently did you use condoms? (Choose one)
__ Never
__ Sometimes.
__ Every time.
__ Don't Know
__ Refuse to Answer
If G63 is equal to 0, then skip to G64.
G64. Number of times you had anal intercourse with partner 4 in past 12 months. (Choose one)
__ none
__ 1 to 3 times
__ 4 to 10 times
__ more than 10 times
__ Don't Know
__ Refuse to Answer
If G64 is equal to 0, then skip to instruction before G70.
G65. When you had anal sex, how frequently did you use condoms? (Choose one)
__ never
__ sometimes
__ every time
__ Don't Know
__ Refuse to Answer
If G65 is equal to 0, then skip to instruction before G70.
Skip to instruction before G70.
G66. Number of times you had insertive anal intercourse with partner 4 in past 12 months. (Choose one)
__ none
__ 1 to 3 times
__ 4 to 10 times
__ more than 10 times
__ Don't Know
__ Refuse to Answer
If G66 is equal to 0, then skip to G68.
G67. When you had insertive anal sex, how frequently did you use condoms? (Choose one)
__ never
__ some times
__ every time
__ Don't Know
__ Refuse to Answer
If G67 is equal to 0, then skip to G68.
G68. Number of times you had receptive anal intercourse with partner 4 in past 12 months. (Choose one)
__ none
__ 1 to 3 times
__ 4 to 10 times
__ more than 10 times
__ Don't Know
__ Refuse to Answer
If G68 is equal to 0, then skip to instruction before G70.
G69. When you had receptive anal sex, how frequently did you use condoms? (Choose one)
__ never
__ some times
__ every times
__ Don't Know
__ Refuse to Answer
If G69 is equal to 0, then skip to instruction before G70.
If G1 is equal to 4, then skip to instruction before H1.
The next set of questions is about your fifth sexual partner, BEFORE your last blood donation.
G70. What is Partner 5's gender?
1 Male
2 Female
7 Don't Know
8 Refuse to Answer
9 Not Applicable
G71. How old is partner 5?
__ __
97 Don't Know
98 Refuse to Answer
G72. What type of partner is partner 5? (Choose one)
1 Anonymous - Did not know, met for sex, never plan to see again
2 One time - Already knew person, but had sex only once
3 Acquaintance - Had sex more than once but not regularly
4 Friend (you socialize with this person) - Had sex more than once but not regularly
5 Main partner - Your spouse or main sex partner
6 Sex worker - Money or other goods were exchanged for sex
7 Don't Know
8 Refuse to Answer
G73. How would you describe partner 5's race or ethnicity? (Choose one)
1 Caucasian
2 Black
3 Asian or yellow
4 Mulatto
5 Indian
7 Don't Know
8 Refuse to Answer
G74. Is partner 5 an injection drug user? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
If G70 is equal to 2 or G70 is equal to 4, then skip to G76.
G75. Is partner 5 a male who has had sex with other males? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
G76. What is partner 5's HIV status? (Choose one)
1 Positive
2 Negative
3 Unknown
7 Don't Know
8 Refuse to Answer
G77. Where did you first meet partner 5? (Choose one)
01 Bar, cafe, nightclub, restaurant, gym or athletic activity.
02 Sex club, bathhouse
03 Street, park, library, public transportation
04 Parties, clubs, political function or church
05 Internet
06 Dating service, newspaper ads
07 Carnival
08 Met some other way
09 Work
98 Refuse to Answer
If G77 is not equal to 8, then skip to instruction before G79.
G78. Specify where you met partner 5:
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
If B1 is equal to 1 and G70 is equal to 1, then skip to G83.
If B1 is equal to 1 and G70 is equal to 2, then skip to G79.
If B1 is equal to 2 and G70 is equal to 1, then skip to G79.
If B1 is equal to 2 and G70 is equal to 2, then skip to instruction before H1.
If B1 is equal to 1 and G70 is equal to 1, then skip to G83.
If B1 is equal to 1 and G70 is equal to 2, then skip to G79.
If B1 is equal to 2 and G70 is equal to 1, then skip to G79.
If B1 is equal to 2 and G70 is equal to 1, then skip to G79.
G79. Number of times you had vaginal intercourse with partner 5 in past 12 months. (Choose one)
__ none
__ 1 to 3 times.
__ 4 to 10 times.
__ more than 10 times.
__ Don't Know
__ Refuse to Answer
If G79 is equal to 0, then skip to G81.
G80. When you had vaginal sex, how frequently did you use condoms? (Choose one)
__ Never
__ Sometimes.
__ Every time.
__ Don't Know
__ Refuse to Answer
If G80 is equal to 0, then skip to G81.
G81. Number of times you had anal intercourse with partner 5 in past 12 months. (Choose one)
__ none
__ 1 to 3 times
__ 4 to 10 times
__ more than 10 times
__ Don't Know
__ Refuse to Answer
If G81 is equal to 0, then skip to instruction before H1.
G82. When you had anal sex, how frequently did you use condoms? (Choose one)
__ never
__ sometimes
__ every time
__ Don't Know
__ Refuse to Answer
If G82 is equal to 0, then skip to instruction before H1.
G83. Number of times you had insertive anal intercourse with partner 5 in past 12 months. (Choose one)
__ none
__ 1 to 3 times
__ 4 to 10 times
__ more than 10 times
__ Don't Know
__ Refuse to Answer
If G83 is equal to 0, then skip to G85.
G84. When you had insertive anal sex, how frequently did you use condoms? (Choose one)
__ never
__ some times
__ every time
__ Don't Know
__ Refuse to Answer
If G84 is equal to 0, then skip to G85.
G85. Number of times you had receptive anal intercourse with partner 5 in past 12 months. (Choose one)
__ none
__ 1 to 3 times
__ 4 to 10 times
__ more than 10 times
__ Don't Know
__ Refuse to Answer
If G85 is equal to 0, then skip to instruction before H1.
G86. When you had receptive anal sex, how frequently did you use condoms? (Choose one)
__ never
__ some times
__ every times
__ Don't Know
__ Refuse to Answer
If G86 is equal to 0, then skip to instruction before H1.
Section H - Alcohol and drug use
Now we are going to ask you some general questions regarding alcohol and drug use. Some types of alcohol or drug use can be related to the risk of becoming infected with HIV. Once again, the following questions are intended to help us determine how to improve the safety of donated blood. We are asking you to respond as truthfully as you can. The answers are anonymous. Your answers will be reported together with all other people who complete the questionnaire.
H1. How often do you drink beer, wine, liquor, or mixed drinks? (Choose one)
0 Never Skip to H7
1 1-3 times per month or less
2 1-2 times per week
3 3-6 times per week
4 Everyday
7 Don't Know
8 Refuse to Answer
H2. On average how many drinks do you have each time you drink? Number of drinks
__ __ __
997 Don't Know
998 Refuse to Answer
H3. Have you ever used any non-injected illegal drugs (drugs that are smoked, snorted or taken orally), examples include marijuana (also called, pot) , hashish, cocaine (also called, blow or crack), methamphetamines (also called, crystal), ecstasy (also called, "e"), mushrooms, and LSD? (Choose one)
0 No Skip to H6
1 Yes
7 Don't Know
8 Refuse to Answer
H4. When was the first year you used non-injected illegal drugs? __ __ __ __ yyyy
2097 Don't Know (Year)
2098 Refuse to Answer (Year)
H5. When was the last year you used non-injected illegal drugs? __ __ __ __ yyyy
2097 Don't Know (Year)
2098 Refuse to Answer (Year)
H6. If you have smoked or snorted illegal drugs, did you share pipes or straws with another person? (Choose one)
1 Always
2 Sometimes
3 Never
7 Don't Know
8 Refuse to Answer
H7. Have you ever used or shot up injection drugs (examples include heroin, cocaine, and amphetamines)? (Choose one)
0 No Skip to instruction before I1
1 Yes
7 Don't Know
8 Refuse to Answer
H8. When was the first year you used injected drugs?
__ __ __ __ yyyy
2097 Don't Know (Year)
2098 Refuse to Answer (Year)
H9. When was the last year you used injected drugs?
__ __ __ __ yyyy
2097 Don't Know (Year)
2098 Refuse to Answer (Year)
H10. Have you ever injected any non-prescription substances including vitamins, anabolic steroids, or hormones? (Choose one)
0 No Skip to instruction before I1
1 Yes
7 Don't Know
8 Refuse to Answer
H11. Have you ever shared needles or syringes with another person to inject any non-prescriptions substance including vitamins, anabolic steroids, or hormones? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
Section I - Medical History
The next set of questions we will ask about some medical treatments you may have had.
I1. Have you ever had a blood transfusion? (Choose one)
0 No Skip to I5
1 Yes
7 Don't Know
8 Refuse to Answer
I2. How many transfusion episodes have you had? __ __
97 Don't Know
98 Refuse to Answer
I3. When was the first year you received a transfusion? __ __ __ __
9997 Don't Know
9998 Refuse to Answer
I4. When was the last year you received a transfusion? __ __ __ __
9997 Don't Know
9998 Refuse to Answer
I5. Have you ever had minor or major medical surgery, tooth extraction or another dental procedure? (Choose one)
0 No Skip to I7
1 Yes
7 Don't Know
8 Refuse to Answer
I6. In the year before your last blood donation, have you had minor or major medical surgery, tooth extraction, or another dental procedure? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
I7. Have you ever had endoscopy (a medical test where a flexible tube is used to look inside of your throat and digestive system) or colonoscopy (a medical test where tube is used to look inside your colon/large intestine)? (Choose one)
0 No Skip to instruction before J1
1 Yes
7 Don't Know
8 Refuse to Answer
I8. In the year before your last blood donation, have you had endoscopy or colonoscopy? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
Section J- Other Potential Risk Factors
The next set of questions we will focus on more general types of risk.
J1. Have you spent three or more nights in jail, prison, or a detention center? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
J2. Have you had acupuncture treatments? (Choose one)
0 No Skip to J5
1 Yes
7 Don't Know
8 Refuse to Answer
J3. How many times have you had acupuncture treatments? (Choose one)
1 1 time
2 2 to 5 times
3 5 or more times
7 Don't Know
8 Refuse to Answer
J4. In the year before your last blood donation, have you had acupuncture treatments? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
J5. How many tattoos do you have on your body? (Choose one)
0 0 (No tattoos) Skip to J8
1 1
2 2
3 3 or more
7 Don't Know
8 Refuse to Answer
J6. In the year before your last blood donation, have you had a new tattoo or had one re-applied? (Choose one)
0 No Skip to J8
1 Yes
7 Don't Know
8 Refuse to Answer
J7. Where did you get your most recent tattoo? (Choose one)
1 Tattoo parlor
2 At home, a friends place, or at parties/raves
3 Jail
4 Other
7 Don't Know
8 Refuse to Answer
J8. How many ear or body piercings do you have? (Choose one)
0 0 (No piercings) Skip to J11
1 1
2 2
3 3 or more
7 Don't Know
8 Refuse to Answer
J9. In the year before your last blood donation, have you had new ear or body piercings? (Choose one)
0 No Skip to J11
1 Yes
7 Don't Know
8 Refuse to Answer
J10. Where did you get your most recent piercing? (Choose one)
1 Pharmacy or medical clinic
2 Tatoo/piercing parlor
3 At home, a friends place, or at parties/raves
4 Jail
5 Other
7 Don't Know
8 Refuse to Answer
J11. Have you ever had a manicure or pedicure at a beauty salon or had a shave at a barbershop? (Choose one)
0 No Skip to instruction before J14
1 Yes
7 Don't Know
8 Refuse to Answer
J12. How many times have you had manicures or pedicures or shaves at a barbershop? (Choose one)
1 1 time
2 2 to 5 times
3 5 or more times
7 Don't Know
8 Refuse to Answer
J13. In the year before your last blood donation, have you had a manicure or pedicure or had a shave at a barber shop? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
Now, we would like to know about any personal contact you have had with persons who either have AIDS or have tested positive for HIV. In each question, please include only family members, personal friends or acquaintances. (If you are a health care worker, please do NOT include any individuals you have given professional care to, we will ask about those contacts in a minute).
J14. How many people do you personally know who currently have AIDS or have died of AIDS? (Choose one)
0 0 (none)
1 1
2 2 to 4
3 5 or more
7 Don't Know
8 Refuse to Answer
J15. How many people do you personally know who do NOT have AIDS, but have tested positive for HIV, the virus that causes AIDS? (Choose one)
0 0 (none)
1 1
2 2 to 4
3 5 or more
7 Don't Know
8 Refuse to Answer
Section K - Work Place Exposures
K1. In your profession, do you take care of humans or have exposure to their bodily fluids? (Choose one)
0 No Skip to instruction before L1
1 Yes
7 Don't Know
8 Refuse to Answer
K2. In your professional work have you ever had a needle stick injury (accidentally been stuck by a needle or other sharp instrument used for providing medical care to someone else)? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
K3. In your professional work have you ever had someone else's blood, body fluids, or excrement splashed into your eyes, mouth or in an open skin lesion? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
If A2 is equal to 1, then skip to end of questionnaire.
Section L - Exposure and Treatment
This is the final section of the questionnaire. It may be difficult for you to respond to these questions. Again, the responses are anonymous and will help us improve blood safety in Brazil.
L1. Did you know your HIV status before donating? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
L2. How do you think you may have become infected with HIV?
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
L3. When do you think you may have been infected with HIV?
__ __ / __ __ __ __ mm / yyyy
2097 Don't Know (Year)
2098 Refuse to Answer (Year)
L4. Are you currently taking antiretroviral therapy? (Choose one) 0 No
1 Yes
7 Don't Know
8 Refuse to Answer
9 Not Applicable
L5. Have you taken antiretroviral therapy in the past? (Choose one) 0 No
1 Yes
7 Don't Know
8 Refuse to Answer
9 Not Applicable
Thank you for taking the time to complete this questionnaire. Please let your host know that you have finished the interview. If you have any questions or concerns, please talk to the research assistant or nurse. You can also contact the medical director at our blood bank.
Public reporting burden for this collection of information is
estimated to average 24 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the
collection of information. An agency may not conduct or sponsor,
and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing
this burden, to: NIH, Project Clearance Branch, 6705 Rockledge
Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0486). Do
not return the completed form
to this address.
Page
HIV case control version 26Nov2007
| File Type | application/msword |
| File Title | HIV Case Control Study |
| Author | Susan Yurgalevitch |
| Last Modified By | curriem |
| File Modified | 2009-02-12 |
| File Created | 2009-02-12 |