Screening Form (UNCG)

HIV/AIDS Risk Reduction Interventions for African-American

Heterosexual Men

0920-10CM

Attachment 3c

Data Collection: Screening Form – UNCG

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

HIV/AIDS Risk Reduction Interventions for African-American

Heterosexual Men:

Screening Form – UNCG (Attachment 3c)

Public reporting burden of this collection of information is estimated to average 5 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 persons 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 (0920-09XX)

Screening Instrument

Blue Questions: Eligibility questions for the project. * indicates the inclusion answer

Red Questions: Exclusionary questions * indicates the exclusionary answer

Demographic Information
Which one of these groups would you say best represents your race or ethnicity? (please check one)	1 Black, not Hispanic * 2 White, not Hispanic 3 Asian or Pacific Islander 4 American Indian or Alaskan Native 5 Hispanic 6 Other [specify] __________________
Do you consider yourself to be a: (check one)	 Male *  Female
What is your age?*	__________________
Are you currently enrolled as a student at?	Yes, UNCG * Yes, NC A&T * Yes, Other school No, I’m not a student
What is your current educational classification (choose one)?	Freshman Sophomore Junior Senior/graduating Date:_________ Senior/not graduating None of the above
What is your current major?	__________________
Sexual Health and Health Behavior Questions
In general, how would you rate your personal health?	1 Excellent 2 Very good 3 Good 4 Fair 5 Poor
Have you participated in any focus groups, individual interviews or component testing groups sponsored by Brothers Leading Healthy Lives?	1 yes * 2 no
Have you been enrolled in an HIV prevention program in the past six months?	1 yes * 2 no
Have you ever been tested for HIV? Do not count tests you may have had as part of a blood donation.	1 yes 2 no *
What is your HIV status?	1 HIV positive 2 HIV negative * 3 Don’t Know/Not Sure *
How many women have you had vaginal or anal sex with in the last three (3) months?*	­­­­­­­­­­­­­­­­­­_____________
___________In the last three months have you had vaginal or anal sex with a woman without using a condom?	1 yes * 2 no
When you think about your sexual activity over the past three months, how likely was it that you would use a condom during vaginal or anal sex with a woman? (select the response that best reflects your experience over the past three months)	1 Never use a condom 2 Sometimes use a condom 3 Usually use a condom 4 Always use a condom
In the last five years, have you had oral or anal sex with a man?	1 yes * 2 no
Have you injected illicit drugs in the past 3 years?	1 yes * 2 no
Have you been enrolled in a substance abuse prevention program in the past six months?	1 yes * 2 no

Thank you for taking our survey for the Brothers Leading Healthy Lives project.