Form 1 Survey

OMB No. XXXX-XXXX
Expires XX/XX/20XX

ATTACHMENT C

KEY INFLUENCER SURVEY INSTRUMENT

National Survey on Knowledge, Attitudes, and Behaviors

Related to HIV Vaccine Research

We need your assistance to improve our understanding of attitudes related to HIV vaccine research. In appreciation for your assistance, a gift code worth $25 at Amazon.com will be provided to you at the end of this survey.

More than 1,000,000 Americans are thought to be infected with Human Immunodeficiency Virus (HIV), the virus that causes Acquired Immune Deficiency Syndrome (AIDS). The National Institute of Allergy and Infectious Disease (NIAID) at the National Institutes of Health (NIH) is working with researchers to develop a vaccine that prevents HIV infection. Survey data will guide efforts to educate the public about clinical trials, which are a necessary part of the development of an effective vaccine.

You have been selected for participation in this survey because of your affiliation with [ORG NAME], which serves communities that are highly impacted by HIV/AIDS.

Your personal information will be protected to the fullest extent permitted by law. Your answers will be stored separate from your identifying information in a secure environment. During analysis, survey answers will be combined across all respondents and reported in the aggregate. NIAID, the NIAID HIV Vaccine Research Education Initiative and your employer will not be informed of your personal responses to survey questions.

Your participation in this survey is voluntary. Though there are no penalties for not responding to the survey, if you do not respond, the survey finding may not represent your point of view and the final results may be inaccurate.

In about a year we will ask you to fill out a similar survey in order to assess your attitudes at that time.

If you have any questions about the survey, please contact Dan Eckstein:

[email protected]

NOVA Research Company

4600 East-West Highway, Suite 700

Bethesda, MD

(301) 986-1891

Public reporting burden for this collection of information is estimated to average 20 minutes per response. This time includes the length of time allotted for the survey questions. 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN; PRA (0925-0585). Do not return the completed form to this address.

1. What is your current position with respect to [qualifying organization]?

	Board Member
	Executive Officer
	Program Manager/Project Director
	Outreach Worker/Field Worker
	Other (specify):     

2. How long have you been associated with this organization?

	More than 1 year
	Less than 1 year

Now we are going to ask you some questions related to HIV/AIDS.

Awareness

3. How recently have you heard or read about research efforts to develop a vaccine that prevents HIV infection? HIV is the virus that causes AIDS.

	Less than 1 year ago
	1 year or more ago
	I heard about it but I don’t know when
	Not sure if I ever heard about it
	Never heard of it	SKIP to 4

1. From which sources have you read of or heard about research efforts to develop a vaccine that prevents HIV? (Check all that apply).

	TV
	ii. Radio
	iii. Newspaper or Magazine
	iv. Internet:
	Wiki
	Nonprofit Web site
	Government Web site
	Social Networking Web site (e.g., Facebook, Twitter)
	Blog
	v. Non-work-related interpersonal contact (discussion, email)
	vi. E-mail listserv
	vii. Work-related duties (e.g., presentations, healthcare outreach, community work) or interests promoted at work
	viii. Workshop, health fair, brochure, program, or any other activity sponsored by an agency in your community	(specify):      
	ix. Presentation at professional conference/meeting	(specify):      
	x. Other (specify):     
	xi. Don’t know

4. Have you seen “Be The Generation” materials or “Be The Generation” Web Site?

(Check all that apply).

	Yes
	No	SKIP TO 5

1. Did you hear of “Be The Generation” through your work? (Check all that apply).

	No, I didn’t hear of “Be The Generation” through my work	SKIP to 5
	Yes, I’ve heard of “Be The Generation” through my work, but I have not used these materials	SKIP to 5
	Yes, I use these materials in my work now
	Yes, I’ve used these materials in the past
	Other (specify):     

2. How has your organization used “Be The Generation” materials?

(Check all that apply).

	Distributed link to website
	Distributed hard copy materials
	Played “Community Voices” video for constituents
	Other (specify):     )
	Don’t know

Attitudes

5. How relevant is the topic of HIV vaccine research to you, your friends and family, and the community served by [qualifying organization]?

(Check one response in each row).

How relevant is HIV vaccine research to…

	Not Relevant At All	Slightly Relevant	Somewhat Relevant	Very Relevant	Extremely Relevant	Don’t Know
You?
Your family?
Your friends?
Co-workers?
The community served by [qualifying organization]?

6. How much do you agree or disagree with each of the following statements?

(Check one response in each row).

	Strongly Disagree	Some-what Disagree	Don’t Know/ Neither Agree Nor Disagree	Agree	Strongly Agree
I am confident that an effective vaccine for HIV will be developed.
An HIV vaccine is being unfairly withheld as part of discrimination against certain groups.
Volunteers in HIV vaccine trials may become infected with HIV acquired from the vaccine.
I am confident that HIV vaccine clinical trials staff take good care of volunteer participants.
I am concerned that volunteers in an HIV vaccine clinical trial may put their own good health at risk.
Spreading the word about the importance of HIV vaccine research conflicts with outreach on HIV/AIDS prevention.
Development of an HIV vaccine has been delayed because a vaccine would not be profitable for drug companies.
Procedures established in HIV vaccine research are adequate to protect volunteers.
HIV vaccine clinical trial volunteers are counseled to avoid behaviors that can result in exposure to HIV.
The only way to support HIV vaccine research is to volunteer for a clinical trial.
HIV vaccine clinical trials seek only volunteers who are high risk of exposure to HIV.
The benefits of participating in an HIV vaccine clinical trial outweigh the burden or risks of participation to the individual.
If I support HIV vaccine research, it will hurt me socially and/or professionally.
I would feel comfortable initiating conversations about the importance of HIV vaccine research.

7. How open are the people around you to supporting HIV vaccine research? How open are… (Check one response in each row).

	Not at All Open	Not Very Open	Somewhat Open	Very Open	Extremely Open	Don’t Know
a. Your family?
b. Your friends?
c. Co-workers?
d. The community served by [qualifying organization]?

8. How important is it to you to increase support for HIV vaccine research?

(Check one response in each row).

	Not at All Important	Not Very Important	Somewhat Important	Very Important	Extremely Important	Don’t Know

IF you checked “Not at All” or Not Very” Important, SKIP to Question 9.

a. How confident are you that you are able to increase support for HIV vaccine research among… ?

(Check one response in each row).

	Not at All Confident	Not Very Confident	Somewhat Confident	Very Confident	Extremely Confident
Your family?
ii. Your friends?
iii. Your co-workers?
iv. The community served by [qualifying organization]?

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

(Check one response in each row).

	Strongly Disagree	Somewhat Disagree	Don’t Know/ Neither Agree Nor Disagree	Somewhat Agree	Strongly Agree
a. I have the skills needed to spread the word about the importance of HIV vaccine research.
b. I have the knowledge needed to spread the word about the importance of HIV vaccine research.
c. I have the resources and materials to spread the work about the importance of HIV vaccine research.
d. I have the opportunity to speak out about the importance of HIV vaccine research.

9. How willing would you be to…

(Check one response in each row).

	Not at All Willing	Not Very Willing	Somewhat Willing	Very Willing	Extremely Willing	Don’t Know
Provide emotional support for someone participating in a vaccine trial?
Participate in a clinical trial for an HIV vaccine (assuming it was nearby and you were eligible)?
Recommend to a friend that they volunteer for an HIV vaccine trial?
Initiate a conversation with clients of [qualifying organization] about the importance of HIV vaccine trials?
Encourage clients of [qualifying organization] to volunteer for an HIV vaccine trial?

Activities Supportive of HIV Vaccine Research

9. Have top administrators of [qualifying organization] requested or received a briefing regarding the status of HIV vaccine research?

(Check one response).

	Yes
	No
	Don’t Know

9. Have you personally provided information on HIV vaccine research to top administrators of [qualifying organization]?

	Yes
	No
	Don’t Know

9. Have the staff of [qualifying organization] received in-service training related to HIV vaccine research?

	Yes, on site
	Yes, off site
	No
	Don’t Know

14. Has [qualifying organization] raised awareness of HIV vaccine research as an important strategy for controlling the AIDS epidemic? (Check one response).

	Yes How (specify):      
	No
	Don’t Know

14. Does [qualifying organization] provide information about HIV Vaccine Research through…

(Check one response in each row).

Type of Media	Yes	No	Don’t Know
a. The Internet?
b. Hard copy materials?
c. Presentations/ conferences/health fairs?
d. Mass media news releases?
e. Church communities?
f. Community events/festivals?
g. Universities and colleges?
h. Word of mouth?

14. Have you personally provided information to others about HIV vaccine research through…

(Check one response in each row).

Type of Media	Yes	No	Don’t Know
a. Distributing materials?
b. Writing articles or papers?
c. Making presentations
d. Providing interviews?

14. Have you personally championed support for HIV vaccine research within your organization? (Check one response).

	Yes, more than one year ago
	Yes, within the last year
	No

14. Have you personally taken a course or attended a workshop providing training on how to improve support for HIV vaccine research? (Check one response).

	Yes, more than one year ago
	Yes, within the last year
	No

14. In the last three months, about how many times have you engaged in the following activities? (Check one response in each row).

	Not at All	Once or Twice	3 – 5 Times	6 – 8 Times	9 or More Times
Initiated a conversation about HIV vaccine research
Spoken with friends about HIV vaccine research
Recommended to friends that they volunteer for HIV vaccine clinical trials
Spoken to clients of [qualifying organization] about HIV vaccine research
Encouraged clients of [qualifying organization] to volunteer for HIV vaccine clinical trials

14. In the past year, have you worked with or obtained information from any of the following organizations? (Check all that apply in each row).

	Obtained Info	Worked With	Other Contact	No Contact	Don’t Know
NIAID HIV Vaccine Research Education Initiative (NHVREI)
Academy for Educational Development (AED)
AIDS Alliance for Children, Youth, and Families (AACHF)
National AIDS Education and Services for Minorities (NAESM)
AIDS Action Foundation (AAF)
National Minority AIDS Council (NMAC)
National Association of State and Territorial AIDS Directors (NASTAD)

Demographics

14. What is your age? (Check only one).

	Under 21 years
	21-30 years
	31-40 years
	41-50 years
	51-60 years
	61-70 years
	over 70 years

14. What is your gender?

	Male
	Female
	Transgender

14. What is your ethnicity? (Check only one).

	Hispanic or Latino
	not Hispanic or Latino

14. What is your race? (Check all that apply).

	American Indian or Alaska Native
	Asian
	Black or African American
	Native Hawaiian or Other Pacific Islander
	White

14. Which of the following categories best describes the highest educational level you attained? (Check only one).

	Less than a high school degree
	High school degree or GED
	Some college/technical school/associates degree
	College degree
	Some graduate school or more
	Other (specify):     

14. In the United States, African Americans, Hispanics/Latinos, and men who have sex with men (MSM) are populations that have been disproportionately affected by HIV/AIDS. For this reason, NIAID is particularly interested in learning about communities with these characteristics.

Thinking about your social network (your clients, coworkers, friends and family), about how many are members of the following populations?

	None	Some	Many	Most	Don’t Know
People Served by [qualifying organization]
African American
Hispanic/Latino
MSM
Coworkers
African American
Hispanic/Latino
MSM
Family
African American
Hispanic/Latino
MSM
Friends
African American
Hispanic/Latino
MSM

14. Please add any other comments regarding HIV vaccine research of which you believe NIAID should be aware:

     

14. We would like to gather information from other staff from [organization] who have direct contact with the constituents of [organization]. Would you be willing to provide us with the names of two people whom we could contact for participation in this survey?

Name Position Email Telephone

                       

                       

THANK YOU FOR YOUR ASSISTANCE

TO OBTAIN YOUR $25 HONORARIUM, CLICK ON THE LINK BELOW TO GO TO AMAZON.COM.

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