Patient Survey

Attachment 3

Patient Questionnaire

February 3, 2021Form Approved

OMB No. 0920-XXXX

Expiration Date XX/XX/20XX

Patient Survey

Public reporting burden of this collection of information is estimated to average 20 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. CDC may not conduct or sponsor, and a person is not required to respond to a collection of information unless a currently valid OMB control is displayed. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC Information Collections Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (XXXX-XXXX).

THIS QUESTIONNAIRE IS ANONYMOUS

YOUR ANSWERS ARE PRIVATE AND CANNOT BE LINKED TO YOU

Please DO NOT write your name on this questionnaire

1a. Were you offered an HIV test today?

1. □ Yes

   • Did you refuse the test you were offered?

□ I refused the test.

□ I took the test. Please go to question 2

2. □ No. Please go to question 6

1b. Please rate on a scale of 1 to 5, where 1 means “not at all” and 5 means “most important,” how much each of the following reasons affected your decision to refuse the HIV test today.

	0 I prefer not to answer	1 Not at all	2 Very little	3 Somewhat	4 A lot	5 Most important
I don’t think I’m at risk for HIV	□	□	□	□	□	□
I am afraid of finding out the result	□	□	□	□	□	□
I am concerned that someone will learn my HIV status	□	□	□	□	□	□
If I am positive, I may not be able to get health insurance or life insurance	□	□	□	□	□	□
I am afraid that if I am positive, people will treat me differently	□	□	□	□	□	□
I didn’t have time to do the test	□	□	□	□	□	□
I didn’t want to take the test here	□	□	□	□	□	□

IF YOU REFUSED THE TEST TODAY, PLEASE SKIP TO QUESTION 3.

2a. What was the result of the test?

□ Negative

□ Positive

□ Invalid/ indeterminate

□ I don’t know

□ I prefer not to answer

2b. Overall, how would you rate your experience with HIV testing today?

Excellent	Very Good	Good	Fair	Poor	Don’t Know	I prefer not to answer
□	□	□	□	□	□	□

3a. How pressured did you feel to take the test?

I prefer not to Answer	I don’t know	Not at all	A little	Somewhat	A lot	Extremely
□	□	□	□	□	□	□

3b. How much of an obligation or responsibility did you feel you had to take the test?

I prefer not to Answer	I don’t know	Not at all	A little	Somewhat	A lot	Extremely
□	□	□	□	□	□	□

3c. How disappointed do you think people would be if you refused the test?

I prefer not to Answer	I don’t know	Not at all	A little	Somewhat	A lot	Extremely
□	□	□	□	□	□	□

3d. How much did you feel as though you would be disobeying the doctors and/or nurses by refusing the test?

I prefer not to Answer	I don’t know	Not at all	A little	Somewhat	A lot	Extremely
□	□	□	□	□	□	□

3e. How judged did you feel for taking/not taking the test?

I prefer not to Answer	I don’t know	Not at all	A little	Somewhat	A lot	Extremely
□	□	□	□	□	□	□

3f. How rude do you think it would have been to refuse to take the HIV test?

I prefer not to Answer	I don’t know	Not at all	A little	Somewhat	A lot	Extremely
□	□	□	□	□	□	□

3g. How much of a choice do you feel you had about taking the test?

I prefer not to Answer	I don’t know	Not at all	A little	Somewhat	A lot	Extremely
□	□	□	□	□	□	□

3h. How much do you feel like your choice to take or refuse the test was voluntary?

I prefer not to Answer	I don’t know	Not at all	A little	Somewhat	A lot	Extremely
□	□	□	□	□	□	□

3i. How confidential/ private did you feel the HIV test was?

I prefer not to Answer	I don’t know	Not at all	A little	Somewhat	A lot	Extremely
□	□	□	□	□	□	□

3j. When the doctor/nurse gave you your results, how confidential/ private was it?

I prefer not to Answer	I don’t know	Not at all	A little	Somewhat	A lot	Extremely
□	□	□	□	□	□	□

3k. How happy are you with the information you received today about HIV testing?

I prefer not to Answer	I don’t know	Not at all	A little	Somewhat	A lot	Extremely
□	□	□	□	□	□	□

IF YOU DID NOT GET TESTED DURING YOUR VISIT TODAY, PLEASE SKIP TO QUESTION 5.

4a. How happy are you with how long it took to get your results?

I prefer not to Answer	I don’t know	Not at all	A little	Somewhat	Very	Extremely
□	□	□	□	□	□	□

4b. How important do you feel it is for health care facilities to provide counseling to patients about their HIV test results?

I prefer not to Answer	I don’t know	Not at all	A little	Somewhat	A lot	Extremely
□	□	□	□	□	□	□

4c. Do you feel as though HIV testing interfered with your overall care?

I prefer not to Answer	I don’t know	Not at all	A little	Somewhat	A lot	Extremely
□	□	□	□	□	□	□

5a. How important is separate, written informed consent to you?

I prefer not to Answer	I don’t know	Not at all	A little	Somewhat	A lot	Extremely
□	□	□	□	□	□	□

5b. How important is it to you that HIV testing is offered every time you visit a health-care facility?

I prefer not to Answer	I don’t know	Not at all	A little	Somewhat	A lot	Extremely
□	□	□	□	□	□	□

5c. How important do you think it is to have HIV testing as a regular part of health care?

I prefer not to Answer	I don’t know	Not at all	A little	Somewhat	A lot	Extremely
□	□	□	□	□	□	□

6a. How likely do you think it is that medical providers assume people with HIV sleep around?

I prefer not to Answer	I don’t know	Not at all	A little	Somewhat	A lot	Extremely
□	□	□	□	□	□	□

6b. To what extent do you think nurses and doctors treat people who have HIV as if they are contagious?

I prefer not to Answer	I don’t know	Not at all	A little	Somewhat	A lot	All the time
□	□	□	□	□	□	□

6c. How much do you think that nurses and doctors dislike caring for patients with HIV?

I prefer not to Answer	I don’t know	Not at all	A little	Somewhat	A lot	Extremely
□	□	□	□	□	□	□

7a. How would you describe your sexual orientation?

1. □ Heterosexual/ Straight

2. □ Bisexual

3. □ Homosexual/ Gay/ Lesbian/ Queer

4. □ Other (specify __________________________)

5. □ I don’t know

6. □ I prefer not to answer

7b. Have you…? (Mark all that apply)

Within 1 Year

Ever

Never

I don’t know

I prefer not to answer

1. Had sex with the other gender……… □ □ □ □ □

2. Had sex with the same gender…………. □ □ □ □ □

3. Been in jail…………………………….. □ □ □ □ □

4. Injected street drugs……………………. □ □ □ □ □

5. Exchanged sex for money or drugs……. □ □ □ □ □

6. Ever had an STD (like syphilis)………... □ □ □ □ □

7. Ever had an HIV test…………………… □ □ □ □ □

8. If yes, what was the result?

□ Negative

□ Positive

□ I never received the results

□ Invalid/ Indeterminate

□ I don’t know

□ I prefer not to answer

7c. Approximately how many different sexual partners (vaginal or anal sex) have you had in the past year?

1. □ 0 partners

2. □ 1 partner

3. □ 2-5 partners

4. □ 6-10 partners

5. □ 11-50 partners

6. □ More than 50 partners

7. □ I don’t know

8. □ I prefer not to answer

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