Form Approved
OMB No. 0920-0840
Expiration: 01/31/2013
Public
reporting burden of this collection of information is estimated to
average 15 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)
Community-level Assessment (CLA) Form
General
Information (To be entered by MEM staff)
1. Participant ID ______________________ 1a. Screener ID__________________ (Refer to participant ID Master List) |
2. Staff ID ________________________ |
3. Data collection time point: CLA 1 CLA 2 |
4. Data collection date: __ __ / __ __ /__ __ __ __ (MM/ DD/YYYY) |
5. Data collection method: Self-administered by client (handheld device, laptop) Self-administered by client (other method): (Specify ______________________________ ) Provider-administered (in-person) Provider-administered (by phone) |
Participant
Information (To be completed by participant)
The first set of questions will ask about your general background.
1a. What is your zip code? (Enter 5-digit zip code) Zip code ________
1b. Which language do you speak most times? (Choose one) English Spanish Creole/French Other (specify) ____________________ Decline to answer
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2. 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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3. 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 is other than the choices above)_______________________________________
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4. 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 Q6} Decline to answer
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5. Is this primary partner a male or female? (Choose one) Male Female Decline to answer
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6. What best describes your employment status? (Choose one) Employed full-time Employed part-time Unemployed Decline to answer
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7. Are you currently a student? (Choose one) Yes (full-time) Yes (part-time) Not a student Decline to answer
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8. 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 set of questions will ask you about your testing experiences regarding HIV and other sexually transmitted diseases.
9. Have you ever been tested for HIV? (Choose one) Yes No (Skip to Q15) Don’t know (Skip to Q15) Decline to answer (Skip to Q15)
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10. What was the result of your last HIV test? (Choose one) Positive (Skip to Q12) Negative Preliminary positive (Rapid test result was positive) (Skip to Q12) Indeterminate (Result was not clear) (Skip to Q13) Don’t know (Skip to Q15) Decline to answer (Skip to Q15)
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11. When was your last negative HIV test? __ __/__ __ __ __ (Skip to Q13) Don’t remember the year (Skip to Q13) Decline to answer (Skip to Q13) |
12. When did you first test positive for HIV? __ __/__ __ __ __ (Skip to Q14) Don’t remember the year (Skip to Q14) Decline to answer (Skip to Q14)
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13. How often do you get tested for HIV? (Choose one) Once every few years Once a year More than once a year Only when I think I have been exposed to HIV I have only tested for HIV once Don’t know Decline to answer
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14. Where did you take your last HIV test? (Choose one) Hospital or emergency room Private doctor’s office Community-Based Organization Health clinic Health fair Correctional facility Shelter Alcohol or drug treatment facility School Other (Specify) ___________________________________ Don’t know Decline to answer |
15. How often do you get tested for other sexually transmitted diseases (not HIV)? (Choose one) Once every few years Once a year More than once a year Only when I think I have been exposed to an STD I have only tested for an STD other than HIV once I have never been tested for other STDs Don’t know 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. Please be as honest as you can in your answers. All information will be kept confidential and cannot be linked to you by name.
16. In the last 3 months, have you used alcohol or drugs? (Choose one) Yes No (Skip to Q22) Don’t know (Skip to Q22) Decline to answer (Skip to Q22)
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17. 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) Ecstasy Hallucinogens such as LSD |
18. In the last 3 months, have you injected drugs? (Choose one) Yes No (Skip to Q22) Decline to answer (Skip to Q22) |
19. Which drugs did you inject (last 3 months)? (Choose all that apply) (Only specify drugs you selected in Q17) 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 Hallucinogens such as LSD |
20. 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 Q22) Don’t know (Skip to Q22) Decline to answer (Skip to Q22) |
21. How often did you share needles/syringes with someone else (last 3 months)? (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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The next set of questions asks about sex behaviors that you may have done in the last 3 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.
22. In the last 3 months, have you had unprotected anal or vaginal sex (without a condom) with a… (Choose all that apply):
Male Female Transgender I have not had unprotected (without a condom) anal/vaginal sex in the last 3 months (Skip to Q27) Decline to answer (Skip to Q27)
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23a. (If you selected yes to male in Q22) In the last 3 months, how many of your male sexual partners that you had unprotected sex (without a condom) with were:
Primary partner(s) Enter # ________ Non-primary partner(s) Enter # ________ Decline to answer
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23b. (If you selected yes to female in Q22) In the last 3 months, how many of your female sexual partners that you had unprotected sex (without a condom) with were:
Primary partner(s) Enter # ________ Non-primary partner(s) Enter # ________ Decline to answer
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23c. (If you selected yes to transgender in Q22) In the last 3 months, how many of your transgender sexual partners that you had unprotected sex (without a condom) with were:
Primary partner(s) Enter # ________ Non-primary partner(s) Enter # ________ Decline to answer
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24. 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 Don’t know Decline to answer
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25. 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 Don’t know Decline to answer |
26. Select all the behaviors below that you did with a male, female, or transgender person in the last 3 months. Had unprotected anal or vaginal sex with someone: … while drunk or high on drugs Male Female Transgender None Decline to answer
… that you met on the Internet
Male Female Transgender None Decline to answer
… so you could get drugs, money, a place to stay, clothing, or something else you needed
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
Male Female Transgender None Decline to answer
… who you knew was an injection drug user
Male Female Transgender None Decline to answer
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… whose HIV status was unknown to you
Male Female Transgender None Decline to answer
… whose HIV status was different from your own HIV status
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)
Male Female Transgender None Decline to answer
… who was over age 30
Male Female Transgender None Decline to answer
I have not done any of these behaviors with male, female, or transgender partners in the last 3 months.
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The next set of questions asks about your thoughts and beliefs about how much you enjoy having sex with a condom whether or not you selected that you have been sexually active in the past 3 months.
27. How satisfying is anal sex when: (Choose one) Not at all Slightly Moderately Very Extremely Don’t Decline to Satisfying satisfying satisfying satisfying satisfying know 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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28. 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 to out of sex out of sex out of sex out of sex out of sex know 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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29. 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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30. 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 Don’t Decline to at all difficult difficult difficult difficult know answer
31. How difficult is it for a man to have an orgasm (cum) while using condoms? 32. How difficult is it for a man to keep his erection (stay hard) when wearing a condom?
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The next few questions ask about your thoughts and beliefs about how difficult it is for you to practice safer sex whether or not you selected that you have been sexually active in the past 3 months.
Not difficult Slightly Moderately Very Extremely Don’t Decline to at all difficult difficult difficult difficult know answer
33. If a man you are having sex with starts to do something unsafe sexually, how difficult is it for you to stop him? 34. If you are really turned on, how difficult is it for you to use a condom? 35. How difficult is it for you to tell a male sex partner not to do something you think is risky? 36. How difficult is it for you to let a male sex partner know that you want to practice safe sex?
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The next few questions relate to what you think your friends believe about safer sex.
37. 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 Q41) Don’t know Decline to answer
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38. 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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39. 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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40. 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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Please indicate how much you agree or disagree with each of the following statements.
41. 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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42. 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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43. 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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44. 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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45. Being with my gay/bi/transgender friends helps me feel good about myself. (Choose one) Disagree strongly Disagree moderately Disagree slightly Agree slightly Agree moderately Agree strongly I don’t have gay/bi/transgender friends (Skip to Q53) Don’t know Decline to answer
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46. 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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47. 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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48. 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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The next few questions involve you talking with your friends about safer sex and HIV testing.
How many times in the past 3 months have the following things happened?
49. You encouraged a gay/bi/transgender friend to have safer sex? Enter # ________
50. A gay/bi/transgender friend encouraged you to have safer sex? Enter # ________
51. You encouraged a gay/bi/transgender friend to take an HIV test? Enter # ________
52. A gay/bi/transgender friend encouraged you to take an HIV test? Enter # ________
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The next set of questions asks about messages you may have seen lately and, also, activities in which you may have participated.
53. Before you began to complete this survey, had you heard of [LOCAL PROGRAM NAME] or participated in activities hosted by [LOCAL PROGRAM NAME]?
Yes No (Skip to Q59) Don’t know (Skip to Q59) Decline to answer (Skip to Q59)
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54. Which of the following have you experienced in the past 3 months? (Check all that apply) Saw a [LOCAL PROGRAM NAME] ad encouraging me to be safe or use condoms, or a [LOCAL PROGRAM NAME] ad promoting local HIV prevention activities # of times _______ Saw HIV prevention outreach sponsored by [LOCAL PROGRAM NAME] in a local bar or other community location # of times _______ Had a discussion about HIV prevention, safer sex, HIV testing, or received condoms from someone involved with [LOCAL PROGRAM NAME] # of times _______ Picked up free condoms and/or lube at a [LOCAL PROGRAM NAME] event # of times _______ Visited the [LOCAL PROGRAM NAME] website, Facebook, MySpace or Tumblr pages # of times _______ Visited the [LOCAL PROGRAM NAME] project space (located at __________________________________) # of times _______ Volunteered for [LOCAL PROGRAM NAME] # of times _______ Attended a [LOCAL PROGRAM NAME] event # of times _______ I have not experienced any of these in the past 3 months Don’t know Decline to answer
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55. Which of the following components of [LOCAL PROGRAM NAME] do you think has had the biggest effect on your safer sex practices? (Choose one)
[LOCAL PROGRAM NAME] ’s website, Facebook, or MySpace pages E-mails or texts sent by [LOCAL PROGRAM NAME] [LOCAL PROGRAM NAME] project space (located at ______ ______________________________) [LOCAL PROGRAM NAME] outreach conducted at bars and clubs [LOCAL PROGRAM NAME] outreach conducted at community events and/or venues Small [LOCAL PROGRAM NAME] activities (e.g., TV/movie nights, game nights, sporting events, etc.) Large [LOCAL PROGRAM NAME] activities (e.g., dances, BBQs, picnics, parties, balls) M- groups [LOCAL NAME] Small discussion groups [LOCAL NAME] [LOCAL PROGRAM NAME] core group meetings I don’t believe [LOCAL PROGRAM NAME] has had any effect on my safer sex practices
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56. Which of the following components of [LOCAL PROGRAM NAME] do you think has had the biggest effect on the safer sex practices of young gay men in the [CITY] area? (Choose one)
[LOCAL PROGRAM NAME] ’s website, Facebook, or MySpace pages E-mails or texts sent by [LOCAL PROGRAM NAME] [LOCAL PROGRAM NAME] project space (located at ______ ______________________________) [LOCAL PROGRAM NAME] outreach conducted at bars and clubs [LOCAL PROGRAM NAME] outreach conducted at community events and/or venues Small [LOCAL PROGRAM NAME] activities [e.g., TV nights, movie nights, game nights, and sporting events (kickball, volleyball, etc.)] Large [LOCAL PROGRAM NAME] activities [e.g., dances, BBQs, picnics, parties (NAMES OF SPECIFIC EVENTS?)] M- groups [LOCAL NAME] Small discussion groups [LOCAL NAME] [LOCAL PROGRAM NAME] core group meetings on _____________ nights I don’t believe [LOCAL PROGRAM NAME] has had any effect on safer sex practices of young gay men in the [CITY] area
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57. Which of the following components of [LOCAL PROGRAM NAME] do you think has had the biggest effect on community building among young gay men in the [CITY] area? (Choose one)
[LOCAL PROGRAM NAME] ’s website, Facebook, or MySpace pages E-mails or texts sent by [LOCAL PROGRAM NAME] [LOCAL PROGRAM NAME] project space (located at ______ ______________________________) [LOCAL PROGRAM NAME] outreach conducted at bars and clubs [LOCAL PROGRAM NAME] outreach conducted at community events and/or venues Small [LOCAL PROGRAM NAME] activities [e.g., TV nights, movie nights, game nights, and sporting events (kickball, volleyball, etc.)] Large [LOCAL PROGRAM NAME] activities [e.g., dances, BBQs, picnics, parties (NAMES OF SPECIFIC EVENTS?)] M- groups [LOCAL NAME] Small discussion groups [LOCAL NAME] [LOCAL PROGRAM NAME] core group meetings on _____________ nights I don’t believe [LOCAL PROGRAM NAME] has had any effect on community building among young gay men in the [CITY] area
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58. How likely are you to use condoms when having anal sex with a man as a result of your involvement with [LOCAL PROGRAM NAME]?
Extremely likely Somewhat likely Neither likely nor unlikely Somewhat unlikely Extremely unlikely
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****** Skip to Q60 ******
59. Which of the following have you experienced 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 # of times _______ Saw HIV prevention outreach in a local bar or other community location # of times _______ Had a discussion about HIV prevention, safer sex, HIV testing, or received condoms from a local outreach worker # of times _______ Had a discussion about HIV prevention, safer sex, HIV testing, or received condoms from a friend # of times _______ Picked up free condoms and/or lube # of times _______ Asked someone or searched for information about HIV/AIDS # of times _______ Saw an ad for a different Mpowerment Project [LOCAL NAME] in [CITY] # of times _______ Visited the website for a different Mpowerment Project [LOCAL NAME] in [CITY] # of times _______ Volunteered for an HIV prevention organization # of times _______ Attended an event sponsored by an HIV prevention organization # of times _______ I have not experienced any of these in the past 3 months Don’t know Decline to answer
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60. Which of the following types of activities or groups have you participated in during the past 3 months in [CITY] area? (Check all that apply) Gay social events in the community Called a gay hotline Gay university events Gay religious groups Read gay newspaper or magazine Volunteer work for a gay organization Gay sports groups or activities Meetings of gay organizations (political, social, etc.) Gay political events in the community Gay computer bulletin boards or Internet chat lines Gay self-help groups (e.g., AA, support groups, etc.)
Don’t know Decline to answer None of the above
61b. Where do you usually go to hang out with your friends? (Please list the actual names of the places) ___________________________ |
61. How often did you go to gay bars in the [CITY] area in the last 3 months?
Never A few times About once a month Several times a month About once a week Several times a week Don’t know Decline to answer
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62. How connected have you felt to the gay/bi/transgender community in the [CITY] area during the past 3 months? (Choose one)
Not connected at all Slightly connected Moderately connected Very connected Extremely connected Don’t know Decline to answer
63. How involved have you been with the gay/bi/transgender community in [CITY] during the past 3 months? Not involved at all Slightly involved Moderately involved Very involved Don’t know Decline to answer
64. How do you feel about the gay/bi/transgender community in [CITY] ? [Type your response]
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| 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 |