0920-10CM_Att3g_BL and Assessments SUNY 11[1].15.2010-clean.

HIV/AIDS Risk Reduction Interventions for African-American

Heterosexual Men

0920-10CM

Attachment 3g

Data Collection: Baseline/Follow-up Assessment – SUNY

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

HIV/AIDS Risk Reduction Interventions for African-American

Heterosexual Men: Baseline/Follow-up Assessment – SUNY (Attachment 3g)

Public reporting burden of this collection of information is estimated to average 20 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)

Client Evaluation Assessment

STUDY ID # ____ - ____ ____ ____

INTERVIEW:

___ Baseline

___Follow-up

DATE: ___ / ___ / ___

Practice Items

These first few questions are to help you feel comfortable using the computer to answer questions.

1 Did you have breakfast this morning?

1. Yes

2. No

To practice numeric pad responses, ask:

2 How many brothers and sisters do you have?

1

2

3

4

5

6

7

8

9

10

More than 10

Demographics: BASELINE ONLY

Now we have some background questions. These questions let us know something about the people who participate in this study.

3. How old are you? __ __ If response is less than 18, Stop “Please see the administrator” 98 I decline

4. Where were you born?

1 United States

2 Africa

3 Canada

4 Caribbean

5 Central America

6 Europe

7 South America

8 Other

4a. If not born in the US, how old were you when you first came to live in the United States? __ __#

4b. (if question 4 = 4 or 7) In what country were you born?

1 Puerto Rico

2 Bermuda

3 Bahamas

4 Barbados

5 British Virgin Islands

6 Cuba

7 Dominican Republic

8 Haiti

9 Jamaica

10 Trinidad and Tobago

11 US Virgin Island

12 Guyana

13 Suriname

14 French Guiana

15 Other

5. Do you consider yourself to be Hispanic/Latino?

0 No, not of Hispanic/Latino origin

1 Yes, I am of Hispanic/Latino origin

6. Do you consider yourself… (Check only one box)

1 Black/African American

2 White

3 Asian

4 American Indian/Alaskan Native

5 Native Hawaiian/Other Pacific Islander

7. What is the highest level of education you completed? (Choose one)

1 Did not complete high school
2 Completed high school or GED equivalent
3 Completed vocational/technical/trade school
4 Some college or two year degree
5 Completed college (4 years) or higher

8. Are you currently enrolled in school? 1 Yes - Full time

2 Yes - Part time

0 No

Income/employment

9. What best describes your current employment status? (Choose one)

1 Working full-time

2 Working part-time (including seasonal/work-study, etc.)

3 Not working

10. What was your personal income last year from all sources before taxes? (Choose one)

1 less than $10,000

2 $10,000-19,999

3 $20,000 - 39,999

4 $40,000 - 59,999

5 $60,000 or more

97 Don't Know

Healthcare

11. Do you currently have any health insurance or other medical coverage such as Medicaid, Medicare, private insurance?

0 No

1 Yes

12. Where do you usually go for medical care when you are sick? (Choose one)

1 Community / Free clinic

2 Medical doctor's office

3 Health department

4 Student health center

5 Emergency room

6 Alternative practitioner (e.g., herbalist)

7 Nowhere

8 Other

Jail/prison

13. Have you ever spent at least one night in jail or prison?

0 No

1 Yes

Living situation

14. Where are you currently living/staying most of the time? (Choose one)

1 Your own house or apartment

2 Your parent(s) or another family member's house or apartment

3 At someone else's house or apartment

4 In a shelter, single-room occupancy hotel or some other

residential facility (halfway house, drug treatment)

5 On the street(s) (vacant lot, abandoned building, park, etc.)

8 Other

15. In the last 3 months, how often did you NOT have enough money in the household for rent, food, or utilities (for example, gas, electric, phone)? (Choose one)

0 Very Often

1 Fairly often

2 Once in a while

3 Never

HIV testing

16. Have you ever been tested for HIV?

0 No

1 Yes

16a. Was this in the past year?

0 No

1 Yes

17. Has a healthcare provider ever told you that you have HIV?

0 No

1 Yes

Substance Use

18. Have you ever injected illicit/illegal drugs with a needle? By this we mean drugs that have not been prescribed by your doctor.

0 No skip to 19

1 Yes

18a. (If yes) Have you injected illicit/illegal drugs with a needle in the last 3 years?

0 No

1 Yes

19. In the last 6 months, have you been part of an HIV or drug use prevention research study?

0. No

1. Yes

97 Don’t know

98 I decline

Now we are going to ask you about your sexual behavior. Many of the questions will ask about things that have happened in the last 3 months (since [insert calculated date]).

Sex behaviors (general)

20. Do you have a primary sex partner like a wife, spouse, girlfriend or significant other?

0 No

1 Yes

21. How many different women did you have vaginal or anal sex with in the past 3 months?

__ __# If = 0, skip to 33

22. Was there at least one time in the last 3 months when you did not use a condom?

0 No skip to 24

1 Yes

23. With how many different women did you have vaginal or anal sex without a condom in the last 3 months?

__ __ __ # If = 0, skip to 26

24. Over the last 3 months, how often did you use condoms during vaginal sex?

0 Never

1 Sometimes

2 Often

3 Always

25. Over the last 3 months, how often did you use condoms during anal sex?

0 Never

1 Sometimes

2 Often

3 Always

Sex Exchange

26. In the last 3 months, did you give a woman food, money, drugs, a place to stay or other favors in exchange for sex?

0 No

1 Yes

27. In the last 3 months, did a woman give you food, money, drugs, a place to stay or other favors in exchange for sex?

0 No

1 Yes

Sex and alcohol/ substance use

28. In the past 3 months have you had vaginal or anal sex with your female partners while you were drunk or buzzed on alcohol?

0 No skip to 29

1 Yes

28a. If yes, how often did you use condoms while you were drunk or buzzed on alcohol?

0 Never

1 Sometimes

2 Often

3 Always

29. In the past 3 months have you had vaginal or anal sex with your female partners while high on drugs? (that is…drugs that have not been prescribed by your doctor)

0 No skip to 30

1 Yes

29a. How often did you use condoms during vaginal or anal sex with your female partners while high on drugs in the past 3 months?

0 Never

1 Sometimes

2 Often

3 Always

29b (if yes to Q29) Place a mark next to those drugs you were high on during vaginal and anal sex with your female partners in the past 3 months

(check all that apply)

__ Marijuana (pot, joint, spliff, ganja, weed)

__ Powdered Cocaine

__ Rock or Crack Cocaine

__ Methamphetamines, other amphetamine (Crystal Meth, Speed, Tina, Ice)

__ Poppers (Amyl Nitrate)

__ Ecstasy (E, X, MDMA)

__ Drugs like Special K, GHB (G, GBL), Rohypnol (roofies)

__ Heroin

__ Viagra or similar drugs (Levitra, Cialis)

__ Recreational use of prescription drugs (other than Viagra) to get high

__Other drugs

Communication –HIV status

30. In the last 3 months before you had sex, did you talk about your HIV status (whether or not you have HIV) with every partner, some of your partners or none of your partners?

1 every partner

2 some of my partners

3 none of my partners

31. In the last 3 months before you had sex, did you talk about your partner’s HIV status with every partner, some of your partners or none of your partners?

1 every partner

2 some of my partners

3 none of my partners

32. In the last 3 months, did you have any sexual partners who you believe have HIV?

0 I do not think that any of my partners had HIV

1 I think that at least one of my partners had HIV

97 I don’t know whether or not any of my partners had HIV

33. Do you consider yourself to be… (Choose one)

1 Heterosexual or straight

2 Homosexual/Gay/Same Gender Loving

3 Bisexual

4 Not sure/Questioning

5 Other (Please specify ________)

97 Don’t know

34. Have you ever had sex with a man?

0 No skip to instructions before question 35

1 Yes

34a (If yes) Have you had oral or anal sex with a man in the last 5 years?

0 No

1 Yes

Earlier we asked you to self identify your race. Now we would like to know how other people have treated you in the last 12 months.

BRFSS – Reactions to Race

35. Within the last 12 months at work, do you feel you were treated worse than other races or ethnicities, the same as other races or ethnicities, better than other races or ethnicities?

Worse than other race or ethnicities…... ……….1

The same as other races or ethnicities…………..2

Better than other races or ethnicities …..……….3

Don’t know 99

36. Within the last 12 months, when seeking health care, do you feel your experiences were worse than other races or ethnicities, the same as other races or ethnicities, better than other races?

Worse than other race or ethnicities…... ……….1

The same as other races or ethnicities…………..2

Better than other races or ethnicities …..……….3

Don’t know 99

I decline .98

37. Within the last 30 days, how often have you felt emotionally upset as a result of how others treated you based on your race or ethnicity , for example angry, sad, or frustrated?

Never 1

At least once 2

At least once a week 3

At least once a day 4

At least once an hour 5

Constantly 6

I decline 98

DON'T KNOW 99

INTERVENTION EXPOSURE

38. Are you a customer at XX Barbershop? ___yes ___no

38a. If no, when was the last time you were at XX Barbershop?

____ In the last 30 days

____ More than 30 days ago but less than 2 months

____ More than 2 months ago but less than 3 months

____ More than 3 months ago but less than 4 months (END INTERVIEW)

____ More than 4 months ago (END INTERVIEW)

____ Don’t Know

____ Refused

38b. If yes, How many times in the last 3 months did you get services at XX Barbershop?

____ None

____ 1 time

____ 2 times

____ 3 times

____ 4 times

____ 5 times

____ 6 times

____ 7 times

____ 8 times

____ 9 times

____ 10 times

____ 11 times

____ 12 times

____ More than 12 times

___ Don’t Know

___ Refused

39. In the last 3 months, did anyone at XX Barbershop speak to you about your health?

____No

____Yes

____Don’t Know

____Refused

40. In the last 3 months, did anyone at XX Barbershop talk to you about HIV?

____No

____Yes

____Don’t Know

____Refused

41 In the last 3 months, did anyone at xx Barbershop give you anything to read about HIV?

____No

____Yes

____Don’t Know

____Refused

42. Overall, do you think that the barbershop is a good place to give customers information about HIV?

____No

____Yes

____Don’t Know

____Refused

43. How satisfied are you with the HIV-related information that you were given at the XX Barbershop?

____Dissatisfied

____Neither satisfied nor dissatisfied

____Somewhat satisfied

____Very satisfied

____I did not receive any HIV-related information(END INTERVIEW)

____Don’t Know

____Refused

44. In the last 3 months, how much do you feel you learned about HIV while at xx Barbershop?

_____ I learned a lot about HIV

_____ I learned a little about HIV

_____ I learned nothing about HIV (END INTERVIEW)

_____ Don’t know

_____ Refused

45. (If learned anything) Have you discussed the information you learned about HIV with any of your friends, family and/or others?

____No

____Yes

____Don’t Know

____Refused

Sex Behaviors (Specific)

Over the past 3 months, which was around (DATE), did you have any female regular partners? This would include a girlfriend, wife, or someone else who is close to you.

____No

____Yes

____Don’t Know

In the next 3 months, if you wanted to convince all of your main female sexual partners to use condoms, how confident or unconfident are you that they would?

_____EXTREMELY CONFIDENT

_____MODERATELY CONFIDENT

_____SLIGHTLY CONFIDENT

_____UNSURE

_____SLIGHTLY UNCONFIDENT

_____MODERATELY UNCONFIDENT

_____EXTREMELY UNCONFIDENT

____Don’t Know

____Refused

In the next 3 months, how favorable or unfavorable do you feel about always using condoms with your regular female sexual partners?

____EXTREMELY FAVORABLE

____MODERATELY FAVORABLE

____SLIGHTLY FAVORABLE

____UNSURE

____SLIGHTLY UNFAVORABLE

____MODERATELY UNFAVORABLE

____EXTREMELY UNFAVORABLE

____Don’t Know

____Refused

Overall, how do think people who are important to you feel about your ability to always use condoms with your main female sexual partners during the next 3 months?

____THINK I DEFINITELY SHOULD NOT

____THINK I PROBABLY SHOULD NOT

____UNSURE

____THINK I PROBABLY SHOULD

____THINK I DEFINITELY SHOULD

____Don’t Know

____Refused

Overall, how likely or unlikely will you always use condoms with your main female sexual partners during the next 3 months?

____EXTREMELY LIKELY

____MODERATELY LIKELY

____SLIGHTLY LIKELY

____UNSURE

____SLIGHTLY UNLIKELY

____MODERATELY UNLIKELY

____EXTREMELY UNLIKELY

____Don’t Know

____Refused

Over the past 3 months, which was around (DATE), did you have any casual female partners? These are partners other than your main partners.

____No

____Yes

____Don’t Know

____Refused

In general, how confident or unconfident do you feel that you could convince all of your casual female sexual partners to use condoms if you wanted to during the next 3 months?

_____EXTREMELY CONFIDENT

_____MODERATELY CONFIDENT

_____SLIGHTLY CONFIDENT

_____UNSURE

_____SLIGHTLY UNCONFIDENT

_____MODERATELY UNCONFIDENT

_____EXTREMELY UNCONFIDENT

____Don’t Know

____Refused

Overall, how favorable or unfavorable do you feel about always using condoms with your casual female sexual partners during the next 3 months?

____EXTREMELY FAVORABLE

____MODERATELY FAVORABLE

____SLIGHTLY FAVORABLE

____UNSURE

____SLIGHTLY UNFAVORABLE

____MODERATELY UNFAVORABLE

____EXTREMELY UNFAVORABLE

____Don’t Know

____Refused

Overall, how do people who are important to you feel about you always using condoms with your casual female sexual partners in the next 3 months?

____THINK I DEFINITELY SHOULD NOT

____THINK I PROBABLY SHOULD NOT

____UNSURE

____THINK I PROBABLY SHOULD

____THINK I DEFINITELY SHOULD

____Don’t Know

____Refused

Overall, do you think that it is more likely or unlikely that you will always use condoms with your casual female sexual partners in the next 3 months? Would you say extremely likely, moderately likely, slightly likely, slightly unlikely, moderately unlikely, or extremely unlikely?

____EXTREMELY LIKELY

____MODERATELY LIKELY

____SLIGHTLY LIKELY

____UNSURE

____SLIGHTLY UNLIKELY

____MODERATELY UNLIKELY

____EXTREMELY UNLIKELY

____Don’t Know

____Refused