Pre-test survey

“Development of a Motion Comic for HIV/STI Prevention Among Young People – ages 15-24”

Attachment 1e. Participant Pre-Test Survey

Form Approved

OMB No. 0920-0840

Expiration Date 01/31/2013

Development of a Motion Comic for HIV/STI Prevention Among Young People – ages 15-24

Participant Pre-Test Survey

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: OMB-PRA (0920-0840)

MOTION COMIC PRE-TEST SURVEY

Study ID No. _____

A. DEMOGRAPHICS.

1. What is the first letter of your middle name? ____ (If you do not have a middle name, write ‘X’.)

2. What month were you born? Circle the month below:

January February March April May June July August September October November December

3. How old are you? ________________ years

4. What sex are you? _____ Male _____ Female _____ Transgender

5. Are you Hispanic or Latino? ____ Yes ____ No

6. What is your race? Select one or more options of the following options.

_____ American Indian or Alaska Native

_____ Asian

_____ Black or African American

_____ Native Hawaiian or Other Pacific Islander

_____ White

7. How do you identify your sexuality?

___ Homosexual/gay/lesbian

___ Heterosexual/straight

___ Bisexual

___ Not sure

8. What is your relationship status?

___Single ___Married ___Divorced ___Separated ___Domestic Partnership

8a.___ not dating anyone seriously 8b.___have a serious bf/gf/or partner

B. SEXUAL HISTORY AND ABSTINENCE/CONDOM USE INTENTIONS

1. Have you ever had sex (vaginal, oral or anal)?

___Yes ___No

1. Who have you had sex with? (check all that apply)

___ Men __Women ____ Transgender

2. Do you think you will have sex sometime in the next 3 months?

____ Yes ____No

3. Do you plan to use protection such as a condom or dental dam if you have sex in the next 3 months?

___ Yes ____No ___ No, I do not plan to have sex in the next 3 months

4. Have you had sex in the last 3 months (90 days)?

___Yes ___No (Skip to section C-Experience and attitudes about HIV Testing)

5. In the past 3 months (90 days), how many people have you had vaginal sex with? ___

6. In the past 3 months (90 days), how many people have you had anal sex with? ____

7. In the past 3 months (90 days), how many people have you had oral sex with? ____

8. Do you currently have a boyfriend/girlfriend or main partner who you are serious with?

__Yes __ No

9. How long have you been in this current relationship? ___

10. The last time you had vaginal sex with your main partner, did you use a condom?

__Yes __ No

11. The last time you had anal sex with your main partner, did you use a condom?

__Yes __ No

12. The last time you had oral sex with your main partner did you use a form of protection such as a condom or dental dam?

__Yes __ No

13. The last time you had vaginal sex with your casual partner, did you use a condom?

__Yes __ No

14. The last time you had anal sex with your casual partner, did you use a condom?

__Yes __ No

15. The last time you had oral sex with your casual partner did you use a form of protection such as a condom or dental dam?

__Yes __ No

C. EXPERIENCE AND ATTITUDES ABOUT HIV TESTING

How much do you agree or disagree with the following statements.

1. a. I am/would be too scared to get an HIV test.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

b. If I was offered a chance to get an HIV test, I would get it.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

c. Everybody who has had unprotected sex should get an HIV test.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

d. I know where to get an HIV test.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

e. I get tested for HIV regularly.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

f. I get an HIV test before I have sex with a new sex partner.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

g. I ask all new sex partners when their last HIV test was and the result.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

h. Everyone regardless of if they are sexually active should get an HIV test.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

2. Have you ever been tested for HIV? HIV is the virus that causes AIDS.

__Yes __No (Skip to question #3)

2a. How many times have you been tested for HIV in your life? # ___

2b. What type of HIV tests have you taken (check all that apply)

___Oral ___ Finger stick ___Blood draw

3. When was your most recent test? You can estimate if you cannot remember exactly.

Month/Year ____________ ___ Don’t remember

2a. What was the result of your most recent HIV test?

___ Positive, I have HIV __ Negative, I do not have HIV __ I did not get my test results

3. Do you plan to get tested for HIV sometime in the next 3 months (90 days)?

__ Yes __ No

D. HIV STIGMA

1. I would sit next to an HIV-positive person.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

2. People who got HIV through sex or drug use have gotten what they deserve.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

3. I would be afraid to live with an HIV-positive person.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

4. I would buy fruit from someone who I knew was HIV-positive.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

5. I would not eat in a restaurant if I found out that someone who was HIV-positive worked there.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

6. I would date someone who is HIV positive.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

F. HIV/STD KNOWLEDGE

Now we will ask you to answer some questions about HIV and STD

1. You can always tell if your partner has as an STD.

___True ___ False

2. All people who have been infected with HIV quickly show serious signs of being infected.

___True ___ False

3. You can’t get HIV by sharing knives, forks, or cups with a person who has HIV.

___True ___ False

4. Wearing a condom correctly will protect you from most STDs.

___True ___ False

5. If a woman uses birth control pills, it lowers her risk for getting HIV.

___True ___ False

6. Using oil based lubricants such as Vaseline or Crisco with condoms will reduce the risk of getting HIV/STD.

___True ___ False

7. There is no cure for HIV.

___True ___ False

8. Having another sexually transmitted disease like Gonorrhea or Herpes increases a person’s risk of becoming infected with HIV.

___True ___ False

9. Having sexual intercourse without a condom increases a person’s risk of becoming infected with HIV/STD.

___True ___ False

10. A person can get HIV by sharing a glass of water with someone who has HIV.

___True ___ False

11. Withdrawal, or pulling out the penis before climax will always prevent HIV/STD transmission.

___True ___ False

12. There is a vaccine (shot) that can prevent people from getting HIV.

___True ___ False

13. There is a vaccine (shot) that can prevent people from getting some STDs.

___True ___ False

14. A person is likely to get HIV by deep kissing (putting their tongue in their partner's mouth) if his/her partner has HIV.

___True ___ False

15. There is a female condom that can help decrease a woman's chance of getting HIV/STD.

___True ___ False

16. A person cannot get HIV if she or he is taking antibiotics.

__True ___ False

17. By taking an HIV test one week after having unprotected sex, it can be determined if a person has been infected.

__True ___ False

F. CONDOM ATTITUDES AND KNOWLEDGE

1. Condoms ruin the mood.

__ Strongly agree __ Agree ___ Neither agree or disagree __ Disagree __ Strongly disagree

2. Sex doesn’t feel as good when you use a condom.

__ Strongly agree __ Agree ___ Neither agree or disagree __ Disagree __ Strongly disagree

3. Sex with condoms doesn’t feel natural.

__ Strongly agree __ Agree ___ Neither agree or disagree __ Disagree __ Strongly disagree

4. I know how to put on a male condom correctly.

__ Strongly agree __ Agree ___ Neither agree or disagree __ Disagree __ Strongly disagree

5. Condoms are easy to use.

__ Strongly agree __ Agree ___ Neither agree or disagree __ Disagree __ Strongly disagree

6. I am embarrassed to ask my partner to use a condom.

__Strongly agree __ Agree __ Neither agree or disagree __ Disagree __ Strongly disagree

7. I would insist on using a condom, even if my partner did not want to use one.

__ Strongly agree __ Agree __ Neither agree or disagree __ Disagree __ Strongly disagree

8. Space should be left at the tip of a condom when it is put on the penis.

__True ___ False

9. The time to put on a condom is right before a man cums or ejaculates.

__True ___ False

10. When a man uses a condom, he should unroll it first and then slip it on.

__True ___ False

G. Behavioral Intentions

1. Thinking of the occasions when you may have sexual intercourse in the next 3 months (90 days), how often do you think you will use condoms?

___Never ___ Occasionally ___About half the time ___Most times ___Always

__Not planning to have sex

2. Thinking of the occasions when you may have sexual intercourse in the next 3 months (90 days), how likely do you think it is you will attempt to negotiate safe sex?

___ Never ___ Occasionally ___About half the time ___Most times ___Always

___ Not planning to have sex

3. Thinking about the next 3 months (90 days) how likely is it you will get an HIV Test

___Extremely unlikely ____ Unlikely ____ Neutral ___ Likely ___Extremely likely

4. Thinking about the next 3 months (90 days) how likely is it you will get an STD Test

___Extremely unlikely ____ Unlikely ____ Neutral ___ Likely ___Extremely likely

5. How likely is it that you will remain abstinent in the next 3 months (90 days)

___Extremely unlikely ____ Unlikely ____ Neutral ___ Likely ___Extremely likely

6. Thinking of the number of sex partners you have had in the last 3 months (90 days), how likely do you think you will reduce the number of partners you will have?

___Extremely unlikely ____ Unlikely ____ Neutral ___ Likely ___Extremely likely

___ Not planning to have sex