Patient Survey

Form Approved

OMB No. 0920-0840
Expiration Date 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)

APPENDIX 1: PARTICIPANT QUESTIONNAIRE

FOR OFFICE USE ONLY

Faculty ID _____ Staff ID _____ Patient ID _____ Date of Interview __________

Assessing the Accuracy of Self-Reported HIV Testing Behavior Questionnaire

Thank you for filling out this form. Please read and answer all questions carefully. Remember that the answers you give will be kept private.

1. What is your date of birth? __ __/__ __/__ __ __ __ (month/day/year)

2. What is your sex?

Male Female

3. What is your ethnicity? (Choose one)

Hispanic Non-Hispanic

4. What is your race? (Choose all that apply)

American Indian/Alaska Native Asian Black/African American

Hispanic/Latino Native Hawaiian/Other Pacific Islander White

5. Have you ever been tested for HIV?

Yes No [skip to Question #12] I don’t know

6. Have you ever had a positive HIV test?

Y es No [skip to Question #9] I don’t know

7. What was the moth and year of the first time you ever tested positive for HIV? List when you were tested, not when you got your results.

__ __/__ __ __ __ (month/year

8. What was the name of the place where you got your first positive HIV test (on the date in question #7? For example, this could be the name of a health clinic, blood bank, doctor’s office or STD clinic.

Site name __________________________________ City/State ____________________

(Offer a drop down bow listing the places where Houston has a partnership allowing review of their medical records. Last choice is “Other – please write in site name and City/State)

9. Have you ever had a negative HIV test result?

Y es No [skip to Question #12] I don’t know

10. What was the month and year that you got your last negative HIV test? List when you got your test, not when you got your results

__ __/__ __ __ __ (month/year

11. What was the name of the place where you got your last negative HIV test (on the date in question #10)? For example, this could be For example, this could be the name of a health clinic, blood bank, doctor’s office or STD clinic.

Site name __________________________________ City/State ____________________

(Offer a drop down bow listing the places where Houston has a partnership allowing review of their medical records. Last choice is “Other – please write in site name and City/State)

12. In the past 3 years, where have you received any of your health care? Please check all that apply.

Site name __________________________________ City/State ____________________

(Offer a drop down bow listing the places where Houston has a partnership allowing review of their medical records. Last choice is “Other – please write in site name and City/State)

END OF SURVEY

Thank you for your time today. Your answers will help us better understand HIV testing