Assessment of a QDS Data Collection System in HIV Prevention Program Evaluation
#0920-0840
Expiration date: 31 January 2013
Assessment of a QDS Data Collection System in HIV Prevention Program Evaluation
QDS Survey
Approval 01/21/2010
OMB control Number 0920-0840
Expiration date: 31 January 2013
Public
reporting burden of this collection of information is estimated to
average 30 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 (0920-0840)
The first set of questions will ask about your general background.
Client
Information (To be completed by client)
1. What year were you born? __ __ __ __ How old are you? __________
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2. In which state do you currently live? _______________ Zip code__________ |
3. What is your ethnicity? (Choose one) Hispanic or Latino Not Hispanic or Latino Don’t know Decline to answer
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4. What is your race? (Choose all that apply) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White Don’t know Decline to answer
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5. Do you speak English? [Choose one] Yes No Decline to answer
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6. Which language do you speak most times? (Choose one) English Spanish Creole/French Other (specify) ____ _______ Decline to answer |
7. What was your sex at birth? (This is the biological sex on your birth certificate.) (Choose one) Male Female Decline to answer
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8. How do you currently identify yourself? (Choose one) Male Female Transgender – Male to female Transgender – Female to male Decline to answer Other (Specify if gender other than the choices above)_______________
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9. Do you consider yourself to be . . . (Choose one) Gay, Homosexual, Same Gender Loving, etc Bisexual Heterosexual or “Straight” Questioning Decline to answer Other (Specify if gender other than the choices above): _________
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10. Are you currently in a primary relationship with someone? This would be someone you live with or see a lot, and to whom you have felt a special emotional commitment or call your boyfriend/girlfriend. (Choose one) Yes No { Skip to Q13} Decline to answer
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11. Is this primary partner a male or female? (Choose one) Male Female Decline to answer
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12. How long have you been with this primary partner? (Choose one) Less than 6 months 6 months to 1 year 1 to 5 years Longer than 5 years Decline to answer
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13. What best describes your employment status? (Choose one) Employed full-time Employed part-time Unemployed Decline to answer
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14. Are you currently a student? (Choose one) Yes (full-time) Yes (part-time) Not a student Decline to answer
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15. What is the highest level of education that you have completed? (Choose one) No schooling completed Bachelor’s degree 8th grade or less Post-graduate (Master’s degree) Some high school Post-graduate (Doctoral-level degree) High school graduate/GED Decline to answer Some college
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These next questions will ask you about your experiences. Some questions may be very personal, but remember that all information you give will be kept private and will not be connected to your name. Please try to be as honest and open as possible. There are no right or wrong answers.
16. Have you been in jail, prison, or juvenile hall for more than a week in the last 3 months? [Choose one] Yes No Decline to answer
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17. Have you ever been tested for HIV? [Choose one] Yes No (Skip to Q22) Don’t know Decline to answer
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18. What was the result of your last HIV test? (Choose one) Positive (Skip to Q20) Negative Preliminary positive (Rapid test result was positive) (Skip to Q20) Indeterminate (Result was not clear) (Skip to Q22) Don’t know Decline to answer
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19. When was your last negative HIV test? __ __/__ __ __ __ (skip to Q22) Don’t remember the year Decline to answer
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20. When did you first test positive for HIV? __ __/__ __ __ __ Don’t remember the year Decline to answer
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21. Are you seeing a primary health care provider (i.e. doctor) for HIV-related care? (Choose one) Yes No Decline to answer
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22. Have you had Syphilis, Gonorrhea or Chlamydia in… Last 12 months? (Choose one) Last 3 months? (Choose one) Yes Yes No (Skip to Q24) No (Skip to Q24) Don’t know Don’t know Decline to answer Decline to answer
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23. Were you told you had Syphilis, Gonorrhea or Chlamydia by a medical provider or were you self-diagnosed? (Choose one) Medical provider Self-diagnosed Decline to answer
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24. Where have you been living primarily for the last 3 months? (Choose one) Stable housing (Includes apartments, houses, foster homes, dorms, long-term residences, housing for military staff, and boarding homes as long as they are not time-limited and do not involve “couch-surfing”.) Non-stable housing (Includes transient or transitional housing shelters, and couch-surfing) Decline to answer
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25. In the past 3 months, were you homeless at any time? That is, you slept in a shelter for homeless people, on the streets, or another place not intended for sleeping. (Choose one) Yes No Decline to answer
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The next set of questions asks about alcohol and drugs that you may have used in the last 12 months.
26. In the last 12 months, have you used alcohol or drugs? (Choose one) Yes No (Skip to Q39) Decline to answer
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27. Which substances have you used (last 12 months)? (Choose all that apply) Alcohol Heroin (injected, smoked, or snorted) Amphetamines, meth, speed, crystal, ice, or crank Hormones, Botox, steroids, silicone Club drugs such as GHB, Ketamine Marijuana Cocaine (injected, smoked, or snorted) Poppers (Amyl nitrate) Crack Other (specify): ________ Downers (Valium, Activan, Xanax) Don’t know Ecstasy Decline to answer Hallucinogens such as LSD
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28. In the last 12 months, have you injected drugs? [Choose one] Yes No (Skip to Q39) Decline to answer
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29. (If you indicated “Yes” in Q28) Which drugs did you inject (last 12 months) (Choose all that apply) Amphetamines, meth, speed, crystal, ice, or crank Heroin Club drugs such as GHB, Ketamine Hormones, Botox, steroids, silicone Cocaine Marijuana Crack Poppers (Amyl nitrate) Downers (Valium, Activan, Xanax) Other (specify): _____ Ecstasy Don’t know Hallucinogens such as LSD Decline to answer
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30. In the last 12 months, have you shared needles, let someone else use your needles, or borrowed someone else’s needles to inject drugs? (Choose one) Yes No Decline to answer
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The next set of questions asks about alcohol and drugs that you may have used in the last 3 months.
31. In the last 3 months, have you used alcohol or drugs? (Choose one) Yes No (Skip to Q39) Decline to answer
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32. Which substances have you used (last 3 months)? (Choose all that apply) Alcohol Heroin (injected, smoked, or snorted) Amphetamines, meth, speed, crystal, ice, or crank Hormones, Botox, steroids, silicone Club drugs such as GHB, Ketamine Marijuana Cocaine (injected, smoked, or snorted) Poppers (Amyl nitrate) Crack Other (specify): ________ Downers (Valium, Activan, Xanax) Don’t know Ecstasy Decline to answer Hallucinogens such as LSD
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33. In the last 3 months, have you injected drugs? (Choose one) Yes No (Skip to Q39) Decline to answer
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34. Which drugs did you inject (last 3 months)? (Choose all that apply) Amphetamines, meth, speed, crystal, ice, or crank Heroin Club drugs such as GHB, Ketamine Hormones, Botox, steroids, silicone Cocaine Marijuana Crack Poppers (Amyl nitrate) Downers (Valium, Activan, Xanax) Other (specify): _____ Ecstasy Don’t know Hallucinogens such as LSD Decline to answer
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35. In the last 3 months, have you shared needles, let someone else use your needles, or borrowed someone else’s needles to inject drugs? (Choose one) Yes No (Skip to Q39) Decline to answer
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36. (If you indicated “Yes” in Q35) Out of all the times you injected drugs in the last 3 months, how often did you share needles/syringes with someone else? (Choose one) Almost never Less than half the time Half the time More than half the time Almost all the time All the time None Decline to answer
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37. (If you indicated “Yes” in Q35) Out of all the times you injected drugs in the last 3 months, how often did you share needles/syringes with someone whose HIV status was unknown to you? (Choose one) Almost never Less than half the time Half the time More than half the time Almost all the time All the time None Decline to answer
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38. (If you indicated “Yes” in Q35) Out of all the times you injected drugs in the last 3 months, how often did you share needles/syringes with someone whose HIV status was different from your own status? (Choose one) Almost never Less than half the time Half the time More than half the time Almost all the time All the time None Decline to answer
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The next set of questions asks about sex behaviors that you may have done in the last 12 months. These questions ask about anal and vaginal sex. They are NOT asking about oral sex (that is, giving/getting blow jobs or head.
***Anal sex means putting your penis (dick) in someone’s anus (butt) or someone putting his penis (dick) in your anus (butt).
***Vaginal sex means putting your penis (dick) in someone’s vagina (pussy).
***Primary partner refers to someone you live with or see a lot, and to whom you have felt a special emotional commitment or call your boyfriend.
39. In the last 12 months, have you had anal or vaginal sex with a… (Choose all that apply)
Male (If checked ask Q39a) Female (If checked ask Q39b) Transgender (If checked ask Q39c) I have not had anal/vaginal sex in last 12 months (Skip to Q51) Decline to answer
39a. (If you indicated “Male” in Q39) In the last 12 months were all of your male sexual partner(s): (Choose one) Primary partner(s) Non-primary partner(s) Both Decline to answer
39b. (If you indicated “Female” in Q39) In the last 12 months were all of your female sexual partner(s): (Choose one) Primary partner(s) Non-primary partner(s) Both Decline to answer
39c. (If you indicated “Transgender” in Q39) In the last 12 months were all of your female sexual partner(s): (Choose one) Primary partner(s) Non-primary partner(s) Both Decline to answer
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40. Select all the behaviors below that you did with a male, female, or transgender person in the last 12 months. Had anal or vaginal sex with someone: … without a condom (Check all that apply for gender or choose none or decline to answer) Male Female Transgender None Decline to answer
… while drunk or high on drugs (Check all that apply for gender or choose none or decline to answer) Male Female Transgender None Decline to answer
… that you met on the Internet (Check all that apply for gender or choose none or decline to answer) Male Female Transgender None Decline to answer
… so you could get drugs, money, a place to stay, clothing, or something else you needed (Check all that apply for gender or choose none or decline to answer) Male Female Transgender None Decline to answer
… who has sex with others so he or she could get drugs, money, a place to stay, clothing, or something else he or she needed (Check all that apply for gender or choose none or decline to answer) Male Female Transgender None Decline to answer
… who you knew was an injection drug user (Check all that apply for gender or choose none or decline to answer) Male Female Transgender None Decline to answer
… whose HIV status was unknown to you (Check all that apply for gender or choose none or decline to answer) Male Female Transgender None Decline to answer
… whose HIV status was different from your own HIV status (Check all that apply for gender or choose none or decline to answer) Male Female Transgender None Decline to answer
… who was anonymous (you do not know the person’s name or have no way to contact the person again in the future) (Check all that apply for gender or choose none or decline to answer) Male Female Transgender None Decline to answer
… who was over age 30 (Check all that apply for gender or choose none or decline to answer) Male Female Transgender None Decline to answer
… who was a hemophiliac/recipient of blood transfusion or transplant (Check all that apply for gender or choose none or decline to answer) Male Female Transgender None Decline to answer
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The next set of questions asks about sex behaviors that you may have done in the last 3 months.
***Anal sex means putting your penis (dick) in someone’s anus (butt) or someone putting his penis (dick) in your anus (butt).
***Vaginal sex means putting your penis (dick) in someone’s vagina (pussy).
***Primary partner refers to someone you live with or see a lot, and to whom you have felt a special emotional commitment or call your boyfriend.
41. In the last 3 months, have you had anal or vaginal sex with a… (Choose all that apply)
Male What is the total # of male partners that you had anal sex within the last 3 months? _______
Female What is the total # of female partners that you had vaginal or anal sex within the last 3 months? ____
Transgender What is the total # of transgendered partners that you had vaginal or anal sex within the last 3 months? _______
I have not had anal/vaginal sex in the last 3 months (Skip to Q51) Decline to answer
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42. In the last 3 months, have you had unprotected anal or vaginal sex (without a condom) with a… (Choose all that apply) Male What is the total # of male partners that you had unprotected anal sex within the last 3 months? _____
Female What is the total # of female partners that you had unprotected vaginal or anal sex within the last 3 months? _____
Transgender What is the total # of transgendered partners that you had unprotected vaginal or anal sex within the last 3 months? _____
I have not had unprotected anal/vaginal sex in the last 3 months (Skip to Q51) Decline to answer
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43. Out of all the times you had anal or vaginal sex in the last 3 months, how often did you have unprotected sex (without a condom)? (Choose one) Almost never Less than half the time Half the time More than half the time Almost all the time All the time Decline to answer
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44. Out of all the times you had anal or vaginal sex in the last 3 months, how often did you have unprotected sex (without a condom) with a primary partner? (Choose one) Almost never Less than half the time Half the time More than half the time Almost all the time All the time I have not had unprotected sex with a primary partner Decline to answer
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45. Out of all the times you had anal or vaginal sex in the last 3 months, how often did you have unprotected sex (without a condom) with a non-primary partner? (Choose one) Almost never Less than half the time Half the time More than half the time Almost all the time All the time I have not had unprotected sex with a non-primary partner Decline to answer
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46. Out of all the times you had anal or vaginal sex in the last 3 months, how often did you have unprotected sex (without a condom) with someone whose HIV status was unknown to you? (Choose one) Almost never Less than half the time Half the time More than half the time Almost all the time All the time I have not had unprotected sex with someone whose HIV status is unknown to me Decline to answer
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47. Out of all the times you had anal or vaginal sex in the last 3 months, how often did you have unprotected sex (without a condom) with someone whose HIV status was different from your own status? (Choose one) Almost never Less than half the time Half the time More than half the time Almost all the time All the time I have not had unprotected sex with someone whose HIV status was different from my own Decline to answer
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48. How many people did you have unprotected anal or vaginal sex (without a condom)? Enter number for each item. … while drunk or high on drugs Male _____ Female ____ Transgender ____ Decline to answer
… that you met on the Internet Male ______ Female ____ Transgender ______ Decline to answer
… so you could get drugs, money, a place to stay, clothing, or something else you needed Male ______ Female ______ Transgender ______ Decline to answer
… who had sex with others so he or she could get drugs, money, a place to stay, clothing, or something else he or she needed Male ______ Female ______ Transgender ______ Decline to answer
… that you knew was an injection drug user Male _____ Female _____ Transgender _____ Decline to answer
… whose HIV status was unknown to you Male _____ Female _____ Transgender _____ Decline to answer
… whose HIV status was different from your own HIV status Male _____ Female _____ Transgender _____ Decline to answer
… that was anonymous (you do not know the person’s name or have no way to contact the person again in the future) Male _____ Female _____ Transgender _____ Decline to answer
… that was over age 30 Male _____ Female _____ Transgender _____ Decline to answer
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48a. (If you indicated that you had sex with a “Male” in Q42) In the last 3 months how many male partner(s) did you have unprotected sex (without a condom) with? Primary partner(s) ____ Non-primary partner(s) ___ Decline to answer
48b (If you indicated that you had sex with a “Female” in Q42) In the last 3 months how many female partner(s) did you have unprotected sex with (without a condom)? Primary partner(s) ___ Non-primary partner(s) ____ Decline to answer
48c. (If you indicated that you had sex with a “Transgender” in Q42) In the last 3 months how many transgendered partner(s) did you have unprotected sex with (without a condom)? Primary partner(s) ____ Non-primary partner(s) ____ Decline to answer
49. (If you indicated that you had unprotected sex while drunk/high in Q48) Which drugs were you using? (Choose all that apply) Alcohol Heroin (injected, smoked, or snorted) Amphetamines, meth, speed, crystal, ice, or crank Marijuana Club drugs such as GHB, Ketamine Poppers (Amyl nitrate) Cocaine (injected, smoked, or snorted) Other (specify): ____________ Crack Don’t know Downers (Valium, Activan, Xanax) Decline to answer Ecstasy Hallucinogens such as LSD |
50. (If you indicated that you had unprotected sex while drunk/high in Q48) Who did you have unprotected anal or vaginal sex with while you were drunk or high? (Choose one) Primary partners Non-primary partners Both Decline to answer
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The next set of questions asks about how much you enjoy having sex with a condom. Please be as honest as you can in your answers. All information will be kept confidential and cannot be linked to you by name.
51. How satisfying is anal sex when: (Choose one) Not at all Slightly Moderately Very Extremely Don’t Decline satisfying satisfying satisfying satisfying satisfying know to answer … your partner is wearing a condom and you are on the bottom? … you are wearing a condom and your partner is on the bottom?
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52. Does it take …(Choose one) A great deal A lot Some A little None of the fun of the fun of the fun of the fun of the fun Don’t Decline out of sex out of sex out of sex out of sex out of sex know to answer … when your partner is wearing a condom and you are on the bottom? … when you are wearing a condom and your partner is on the bottom?
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53. Safer sex is… (Choose one) Much more pleasurable than unsafe sex A little more pleasurable than unsafe sex Equally as pleasurable as unsafe sex. A little less pleasurable than unsafe sex. Much less pleasurable than unsafe sex Don’t know Decline to answer
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54. How much does pausing to put on a condom ruin the sexual mood? (Choose one) Not at all A little A moderate amount A lot A great deal Don’t know Decline to answer
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Not difficult Slightly Moderately Very Extremely at all difficult difficult difficult difficult
55. How difficult is it for a man to have an orgasm while using condoms? (Choose one) 56. How difficult is it for a man to keep his erection stay hard) when wearing a condom? (Choose one)
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The next few questions ask about how difficult it is for you to practice safer sex.
Not difficult Slightly Moderately Very Extremely at all difficult difficult difficult difficult
57. If a man you are having sex with starts to do something unsafe sexually, how difficult is it for you to stop him? (Choose one) 58. If you are really turned on, how difficult is it for you to use a condom? (Choose one) 59. How difficult is it for you to tell a male sex partner not to do something you think is risky? (Choose one) 60. How difficult is it for you to let a male sex partner know that you want to practice safe sex? (Choose one)
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The next few questions relate to what you think your friends think about safer sex.
61. How many of your gay/bi/transgender friends always use condoms when having anal sex with new partners? (Choose one)
None Less than half About half More than half All I don’t have gay/bi/transgender friends (Skip to Q73) Don’t know Decline to answer
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62. How important do your gay/bi/transgender friends think it is to use a condom when having anal sex with a new male partner? (Choose one) Not important at all Slightly important Moderately important Very important Extremely important Don’t know Decline to answer
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63. How many of your gay/bi/transgender friends only engage in safe sex practices? (Choose one) None Less than half About half More than half All Don’t know Decline to answer
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64. How many of your gay/bi/transgender friends think you should always have anal sex with a condom? (Choose one) None Less than half About half More than half All Don’t know Decline to answer
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The next few questions involve you talking to your friends about safer sex.
How many times in the past 3 months have you and your gay/bi/transgender friends... (Choose one)
65. … talked about the importance of having safe sex? Enter # of times ______
Don’t know Decline to answer
66. … shared ideas about how to avoid unsafe sex? Enter # of times ______
Don’t know Decline to answer
67. … encouraged each other to practice safe sex? Enter # of times ______
Don’t know Decline to answer
68. … told each other that you practice safe sex? Enter # of times ______
Don’t know Decline to answer
69. … talked about negotiating condom use with a potential sex partner? Enter # of times ______
Don’t know Decline to answer
70. … given each other condoms or safer sex literature? Enter # of times ______
Don’t know Decline to answer
71. … encouraged each other to get tested for HIV? Enter # of times ______
Don’t know Decline to answer
72. … talked about having taken the HIV antibody test? Enter # of times ______
Don’t know Decline to answer
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The next few questions ask you about your views about men who have sex with men.
73. Do your religious beliefs make you feel any guilt about having sex with other men? (Choose one) No guilt at all A little guilt A moderate amount of guilt A lot of guilt A great deal of guilt Don’t know Decline to answer
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74. Does having sex with other men make you dislike yourself? (Choose one) Not at all A little A moderate amount A lot A great deal Don’t know Decline to answer
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75. Do you ever wish that you were attracted only to women? (Choose one) Not at all A little A moderate amount A lot A great deal Don’t know Decline to answer
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The next set of questions asks about pride in being gay or bisexual.
76. How happy are you about being gay or bisexual? (Choose one) Not at all A little A moderate amount A lot A great deal I don’t consider myself to be gay or bisexual (Skip to Q79) Don’t know Decline to answer
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77. How much pride do you feel in being gay or bisexual? (Choose one) Not at all A little A moderate amount A lot A great deal Don’t know Decline to answer
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78. How comfortable are you with your sexual attraction to other men? (Choose one) Not comfortable at all Slightly comfortable Moderately comfortable Very comfortable Extremely comfortable Don’t know Decline to answer
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Please indicate how much you agree or disagree with each of the following statements.
79. My friends really try to help me if I need it. (Choose one) Disagree Strongly Disagree Moderately Disagree Slightly Agree Slightly Agree Moderately Agree Strongly Don’t know Decline to answer
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80. I can count on my friends when things go wrong. (Choose one) Disagree Strongly Disagree Moderately Disagree Slightly Agree Slightly Agree Moderately Agree Strongly Don’t know Decline to answer
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81. I have friends with whom I can share my joys and sorrows. (Choose one) Disagree Strongly Disagree Moderately Disagree Slightly Agree Slightly Agree Moderately Agree Strongly Don’t know Decline to answer
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82. I can talk about my problems with my friends. (Choose one) Disagree Strongly Disagree Moderately Disagree Slightly Agree Slightly Agree Moderately Agree Strongly Don’t know Decline to answer
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83. Being with my gay/bi/transgender friends help me feel good about myself. (Choose one) Disagree Strongly Disagree Moderately Disagree Slightly Agree Slightly Agree Moderately Agree Strongly I do not have gay/bi/transgender friends (Skip to Q87) Don’t know Decline to answer
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84. Gay/bi/transgender friends provide me with helpful information or advice. (Choose one) Disagree Strongly Disagree Moderately Disagree Slightly Agree Slightly Agree Moderately Agree Strongly Don’t know Decline to answer
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85. My gay/bi/transgender friends are good at helping me solve problems. (Choose one) Disagree Strongly Disagree Moderately Disagree Slightly Agree Slightly Agree Moderately Agree Strongly Don’t know Decline to answer
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86. I have a deep sharing relationship with my gay/bi/transgender friends. (Choose one) Disagree Strongly Disagree Moderately Disagree Slightly Agree Slightly Agree Moderately Agree Strongly Don’t know Decline to answer
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This last set of questions asks about HIV-related messages you may have seen lately and, also, about involvement you may have had in HIV-related activities.
87. Have you experienced any of the following in the past 3 months? (Check all that apply) Saw an ad encouraging me to be safe or use condoms, or an ad promoting local HIV prevention activities Saw HIV prevention outreach in a local bar or other community location Had a discussion about HIV prevention, safer sex, HIV testing, or received condoms from a local outreach worker Picked up free condoms and/or lube Asked someone or searched for information about HIV/AIDS Saw an Mpowerment Project advertisement Visited the Mpowerment Project website I have not experienced any of these in the past 3 months Don’t know Decline to answer
88. How many times have you done any of these in the past 3 months? Enter the # of times that you have volunteered with a local HIV prevention effort _____ Don’t know Decline to answer
Enter the # of times that you have participated in a small-group discussion about safer sex or HIV prevention _ __ Don’t know Decline to answer
Enter the # of times that you have volunteered for the Mpowerment Project __ __ Don’t know Decline to answer
Enter the # of times that you have attended an Mpowerment Project event __ __ Don’t know Decline to answer
Enter the # of times that you have visited the Mpowerment Project space __ ___ Don’t know Decline to answer |
Thank you! You have now finished completing the survey. Please let a staff member know that you are finished.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Supporting Statement for Request for Clearance: |
| Author | Karen Whitaker |
| File Modified | 0000-00-00 |
| File Created | 2021-02-03 |