Survey (attachment 3d)

OMB Change Request for

“Promoting HIV Testing among Low Income Heterosexual Young Adult Black Men”

0920-0869

Attachment 3d. Phase 2 One-on-One Surveys

Form Approved

OMB No. 0920-0869

Expiration Date 10/31/2013

“Promoting HIV Testing among Low Income Heterosexual Young Adult Black Men”

One-on-One Survey

Public reporting burden of this collection of information is estimated to average 30 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-XXXX)

The Phase Two survey was developed based on results from Phase One interviews. The full survey that is being submitted for review with this change request begins on page 4 of this document and measures the following variables:

DATE ________________

TIME BEGIN ____:____

Phase 2 Survey: One-one One Survey (to be completed on ACASI)

[READ TO PARTICIPANT]

The BEATS project invited you to fill out this survey because we are interested in hearing from Black men ages 18-25 who have recently been arrested or released from jail/prison. We hope that the information you give will allow us to develop better health programs for Black men like yourself. It will take about 30 minutes to complete the survey.

Because we are going to be asking about private and personal topics, I want to remind you that everything you write will be anonymous, meaning your name is not on this, so no one will know that you are the one answering the questions.

There are no right or wrong answers. We are just interested in knowing what you really think, so tell us the first answer that comes to mind. We want to know the real deal, because that would be most helpful to us. Do you have any questions?

The first set of questions asks about your opinions about the ways that men should act. For each statement, choose the option that best reflects your answer.

	Strongly Disagree	Disagree	No Opinion	Agree	Strongly Agree
1a. Hugging and kissing should always lead to intercourse.
1b. Nobody likes a man who cries in public.
1c. It is important for a man to take risks, even if he may get hurt.
1d. It is important for a man to be good in bed.
1e. A man should never reveal worries to others.
1f. Boys should be encouraged to find a way to demonstrate physical skill.
1g. One should not be able to tell how a man is feeling by looking at his face.
1h. When the going gets tough, men should get tough.
	Strongly Disagree	Disagree	No Opinion	Agree	Strongly Agree
1i. Men should not be too quick to tell others how they feel about them.
1j. A man shouldn’t bother with sex unless he can have an orgasm.
1k. Men should always take the initiative when it comes to sex.
1l. Fathers should teach their sons to mask fear.
1m. Being a little down in the dumps is not a good reason for a man to act depressed.
1n. Men should get up to investigate if there is a strange noise in the house at night.
1o. For a man, sex should be spontaneous, rather than pre-planned activity.
1p. A man who has no taste for adventure is not very appealing.
	Strongly Disagree	Disagree	No Opinion	Agree	Strongly Agree
1q. For men, touching is simply the first step towards sex.
1r. Men should be detached in emotionally charged situations.
1s. A man shouldn’t have to worry about birth control.

The next set of questions is about some experiences that you may have had as a Black man. Please select the option that matches how often you have had each experience.

	Never	Rarely	Sometimes	Often	Very Often	Always
2a.How often have you felt that it is hard to be a Black man?
2b.How often have you felt that it is a blessing to be a Black man?
2c.How often have you felt that the challenges you have as a Black man make you stronger than other men?
2d.How often have you felt that as a Black man, you could be anything you want to be if you just stay focused and positive?
2e.How often have you felt that if you could be anything other than a Black man, you would?
2f. How often have you felt that it is a constant struggle to be a Black man?
2g. How often have you felt that White people avoid eye contact with you?
	Never	Rarely	Sometimes	Often	Very Often	Always
2 h.How often have White people seemed uncomfortable when they pass you on the street?
2i. How often have White people locked their car doors when you pass by because you are Black?
2j.How often have you been treated rudely or unfairly because you are Black?
2k.How often have you been fired from a job because you are Black?
2l.How often have you not been hired for a job because you are Black?
2m.How often have you been stopped, searched, threatened or abused by the police because you are Black?
2n.How often have you been treated unfairly at the place you work because you are Black?

3. Overall, how much has racial discrimination stopped you from getting the things you want in life?

1. A lot

2. Some

3. A little

4. Not at all

4. Overall, how much harder has your life been because of racial discrimination?

1. A lot

2. Some

3. A little

4. Not at all

The next questions are about your friends and family. Please select your answers.

How many of your friends:

	None	Some	Most	All
5a. Have graduated from college
5b. Have been arrested
5c. Live in a different neighborhood
5d. Are unemployed
5e. Have dropped out of high school
5f. Have a full time job
5g. Have been to jail or prison

How many of your family members:

	None	Some	Most	All
5h. Have graduated from college
5i. Have been arrested
5j. Live in a different neighborhood
5k. Are unemployed
5l. Have dropped out of high school
5m. Have a full time job
5n. Have been to jail or prison

These sentences are about how some young people feel about their lives. After reading each sentence, decide if the sentence is TRUE for you or FALSE for you. Please select whether you feel the sentence is not true at all, true some of the time, true most of the time or true all of the time.

	Not true at all	True some of the time	True most of the time	True all of the time
6a. All I can see ahead of me are bad things, not good things.
6b. There’s no use in really trying to get something I want because I probably won’t get it.
6c. I might as well give up because I can’t make things better for myself.
6d. I don’t have good luck and there’s no reason to think I will when I grow up.
6e. I never get what I want, so it’s dumb to want anything.
6f. I don’t expect to live a very long life.

Thinking back over the last 2 WEEKS, please pick the answer that best describes how often the following events have happened to YOU.

	Never	Sometimes	Often	Very Often
7a. You have been asked for money by drug addicts.
7b. You have taken a longer way to school or work to avoid trouble.
7c. You have been pressured to join a gang or crew.
7d. You have worried that someone will try to take your clothes, shoes, or money.
7e. You have been pressured for sex by boyfriend/girlfriend.
7f. You have been working to help pay bills at home.
7g. You have been nervous about gunshots at night.
7h. You have been nervous about sirens at night.
7i. You have been worrying about safety of friends.
7j. You have been worrying about safety of family members.
7k. You have been worrying about your own safety.
7l. You have not told your friends that you are worried about your safety.
7m. You have been stopped and questioned by police.
7n. You have been asked to sell drugs.
7o. You have been asked to hide or carry drugs.
7p. You have been followed in department stores by salespeople.
	Never	Sometimes	Often	Very Often
7q. You have not been able to go to parties or games with friends because of transportation problems.
7r. You have been teased about the clothes you wear.
7s. You have walked past abandoned buildings and lots.
7t. You have been pressured by friends to fight.
7u. You have been pressured to carry a weapon for protection.
7v. You have had something stolen or had your house or car broken into.
7w.You have been concerned about living in an unsafe area.
7x. You have feared confrontation with strangers.
7y. You have heard loud, noisy cars and neighbors at night.
7z. You have had people hanging around on street corners, in front of stores.
7ai. You have been waiting for a bus at dirty, smelly bus stops.
7aii. Your parent(s) have been “nosey” about what you do.

The next set of questions are about your incarceration history. We realize that these questions are personal and may be sensitive. Please remember that all of your answers will be kept private. (Circle your answers).

8. Have you ever been arrested?

a) 0=No

b) 1=Yes

9. What offense(s) were you charged with on your last arrest?

a) Theft

b) Drug related offense

c) Physical assault

d) Trespassing

e) Other________________

10. Have you ever been to jail? Jail is defined as doing time in a city correctional

facility.

1. 0=No, if no skip to Question 17

b) 1=Yes

11. How long were you in jail during your last conviction?

a) Less than one day

b) Less than one month

c) 1-5 months

d) 6 months- 1 year

e) 1-5 years

f) More than 5 years

12. Have you ever been to prison? Prison is defined as doing time in a federal or state

correctional facility.

a) 0=No, If no skip to Question 14

b) 1=Yes

13. How long were you in prison during your last conviction?

a) Less than one day

b) Less than one month

c) 1-5 months

d) 6 months- 1 year

e) 1-5 years

f) More than 5 years

14. How old were you when you were first incarcerated? _________ year(s)

15. How did you feel while you were incarcerated? Select all that apply.

a) Sad

b) Angry

c) Stressed

d) Lonely

e) Happy

f) Afraid

g) No feelings

h) Other _______________

16. How did you deal with being incarcerated?

Please select all that apply:

	Yes	No
a. Reading
b.Going to school
c.Writing letters
d.Receiving letters
e.Making phone calls
f.Working out
g.Having visitors
h.Staying by yourself
i.Other_________ write out

17. When were you released on your last arrest or incarcerated?

______________ (month/year)

18. Are you on probation?

a) 0=No

b) 1=Yes

19. Have you ever been a member of a gang?

1. 0=No

2. 1=Yes

Now that you are out of jail/prison, please tell us how you are adjusting back to civilian life. On a scale of 1 to 3, with 1 being badly to 3 being well, please tell us how you are doing with the following.

	1 Badly	2 OK but need assistance	3 Well
20 a.Finding a job
20 b.Keeping a job
20.c. Not using drugs
20.d. Not selling drugs
20 e. Not using alcohol
20 f. Finding a place to stay
20.g. Finding supportive people
20 h. Staying away from illegal activities
20 i. Not hanging out in your old neighborhood
20 j. Not hanging out with old affiliates
20 k. Hanging out with your new circle of friends
20l. Spending time with your family
20 m. Spending time with your your girlfriend/wife
20 n.. Spending time with your kid(s)
20 o. Getting health care
20 p. Getting welfare
20 q. Getting into school or a training program
20 r. Staying in school or a training program
20 s. Getting money
20 t. Getting enough to eat every day
20 u. Other: _________write out

You have reached halfway through the survey. Your responses are important to us, so please continue answering all the questions to the end.

As I mentioned earlier, one of the reasons we are doing this interview is to learn how to develop better health programs for young Black men like yourself. Knowing about your experiences getting health care will help us do this. Please answer the following questions about your health.

21. How healthy do you think you are?

a) Excellent

b) Good

c) Okay

d) Poor

22. State the reason for the health rating you listed in Question 21 (choose all that apply)

a) I provided that rating because that is the way I feel.

b) I provided that rating because of signs or symptoms of illnesses/diseases.

c) I provided that rating because of past illnesses or diseases I have had.

d) I provided that rating because of a recent doctor visit.

e) Other (please list): ___________________________

23. While you were incarcerated, did you get any health care? (Circle your answer).

a) 0=No

b) 1=Yes

24. What type of health issues have you had in the past year? (Select all that apply)

a) Allergies, including asthma

c) Eye sight problems

d) High blood pressure

e) Diabetes

f) Stomach problems

g) Hepatitis

h) Heart problems

i) Bronchitis

j) Sickle-cell anemia

k) Sexually Transmitted Infection (e.g., Chlamydia, Herpes)

l) Other _____________________________

25. Have you experienced any mental health issues in the past year?

1. 0=No, if no skip to Question 27

b) 1=Yes

26. Have you experienced any of the following mental health issues in the past year?

(Select all that apply)

a) Depression

b) Anxiety

c) Bipolar disorder

d) Schizophrenia

e) Other_________________

27. In the month before your last arrest/incarceration, how often did you use the following substances?

	Never	Occasionally (once a month)	Regularly (once a week or more)	Daily (everyday)
27 a. Smoked marijuana
27 b.Used PCP (angel dust)
27 c. Took MDMA (ecstasy)
27 d. Used cocaine powder
27 e. Used heroin
27 f. Used a needle to inject any drug
27 g. Used crystal meth
27 h. Took steroids
27 i. Used inhalants
27 j. Smoked crack
27 k. Took prescription medication
27 l. Took over-the-counter medication
27 m. Other:

The next questions are about your sexual experiences. Please remember that everything you say is private and your name is not on the survey, so please be as honest and open as you can.

28. Have you ever had sex? By sex, I mean any kind of sex (oral, anal or vaginal sex) (Circle your answer).

a) 0=No, skip to Question 62

b)1=Yes

29. How old were you the first time you willingly had vaginal sex (i.e., you place your penis in someone’s vagina)?

_____ years

30. Before your arrest/incarceration, did you usually drink alcohol before you had sex?

a)_____ALWAYS

b)_____ALMOST ALWAYS

c)_____SOMETIMES

d)_____NEVER

31. Before your arrest/incarceration, did you usually use illegal drugs (for example, cocaine, marijuana, ecstasy) before you had sex?

a)_____ALWAYS

b)_____ALMOST ALWAYS

c)_____SOMETIMES

d)_____NEVER

32. Have you ever had sex while incarcerated?

1. 0=No, skip to Question 36

2. 1=Yes

33. If yes, with who? Please circle all that apply:

a) Girlfriend

b) Child’s mother

c) Female friend

d) An inmate

e) Correctional staff

f) Other Jail/prison staff

g) Other person

34. Have you ever been forced to have sex while in jail/prison?

a) 0=No

b)1=Yes

35. Have you ever forced anyone to have sex while in jail/prison?

a) 0=No

b)1=Yes

36. Have you had sex since your release from jail/prison?

a)0=No

b)1=Yes

37. If yes, when did you first have sex after your release from jail/prison?

a) Same day as release

b) Next day after release

c) 2-3 days after release

d) 4-5 days after release

e) One week after release

f) More than a week after release

g) Longer than a month after release

Some people have sex with different types of people. There can be a main sex partner, who is someone you have sex with on a regular basis and may also have a friendship/relationship. There can be a casual partner, who is someone you know and have sex with every now and then. There can also be a one-time partner, who you have sex with only once.

38. In the past month, did you have vaginal sex (i.e., you place your penis in someone’s vagina) with a main partner (someone you have sex on a regular basis and also have a friendship/relationship)? (Circle your answer).

a) 0=No, skip to Question 41

b)1=Yes

39. How many main sexual partners have you had vaginal sex with in the past month? _____#

40. In the past month, how often did you use a condom with your main partner(s) during vaginal sex? (Check your answer).

a)_____ALWAYS

b)_____ALMOST ALWAYS

c)_____SOMETIMES

d)_____NEVER

41. In the past month, did you have vaginal sex ( i.e., you place your penis in someone’s vagina) with a casual partner who is someone you know and have sex with every now and then? (Circle your answer).

a)0=No, skip to Question 44

b)1=Yes

42. How many casual partners have you had vaginal sex with in the past month? ________#

43. In the past month, how often did you use a condom with your casual partner(s) during vaginal sex? (Check your answer).

a)_____ALWAYS

b)_____ALMOST ALWAYS

c)_____SOMETIMES

d)_____NEVER

44. In the past month, did you have vaginal sex (i.e., you place your penis in someone’s vagina) with a one time partner. That is someone you had sex with only once? (Circle your answer).

a)0=No, skip to Question 48

b)1=Yes

45. Which of the following have been a one-time partner in the past month? (Choose all that apply)

a) Friend

b) Ex-girlfriend

c) Prostitute

d) Random person/someone you did not know (reword)

e) Other ___________________

46. How many one-time sexual partners have you had vaginal sex with in the past month? ________#

47. In the past month, how often did you use a condom with your one time partners during vaginal sex? (Check your answer).

a)_____ALWAYS

b)_____ALMOST ALWAYS

c)_____SOMETIMES

d)_____NEVER

48. In the past month, did you have oral sex (i.e., you placed your penis in someone’s mouth or they placed their penis or vagina in your mouth)? (Circle your answer).

a) 0=No

b)1=Yes

49. How many partners have you had oral sex with in the past month? ____________#

50. In the past month, how often did you use a condom with your partners during oral sex? (Check your answer).

a)_____ALWAYS

b)_____ALMOST ALWAYS

c)_____SOMETIMES

d)_____NEVER

51. In the past month, did you have oral sex with a man? (Circle your answer).

a)0=No, if no skip to Question 54

b)1=Yes

52 How many male partners have you had oral sex with in the past month? ____________#

53. In the past month, how often did you use a condom during oral sex with a man? (Check your answer).

a)_____ALWAYS

b)_____ALMOST ALWAYS

c)_____SOMETIMES

d)_____NEVER

54. In the past month, did you have anal sex (i.e., you placed your penis in someone’s anus or they placed their penis in your anus? (Circle your answer).

a)0=No, if no skip to Question 59

b)1=Yes

55. How many partners have you had anal sex with in the past month? ____________#

56. In the past month, how often did you use a condom during anal sex? (Check your answer).

a)_____ALWAYS

b)_____ALMOST ALWAYS

c)_____SOMETIMES

d)_____NEVER

57. In the past month, did you have anal sex with a man? (Circle your answer).

a) 0=No if no skip to Question 59

b)1=Yes

58. How many male partners have you had anal sex with in the past month? ___________#

59. In the past month, how often did you use a condom during anal sex with a man? (Check your answer).

a)_____ALWAYS

b)_____ALMOST ALWAYS

c)_____SOMETIMES

d)_____NEVER

60. In the past month, did you have group sex (i.e., you had sex with more than one person the same time or you were part of a ‘train’/group who had sex with one person one right after the other)? (Circle your answer).

a) 0=No, if no go to Question 62

2. 1=Yes

61. Were your group sex partners women, men or both?

a) Mostly Women

b) Mostly Men

c) Equal numbers of men and women

62. In the past month, how often did you use a condom during group sex? (Check your answer).

a)_____ALWAYS

b)_____ALMOST ALWAYS

c)_____SOMETIMES

d)_____NEVER

63. The next statements are about the advantages and disadvantages of using condoms. Please tell us how important the following is to you in your decision to use condoms.

	Not at all	Somewhat Important	Very Important	Extremely Important
63 a. I would be safer from disease.
63 b. Condoms would protect my partner and myself.
63 c. I would feel more responsible.
63 d. My partner would not become pregnant.
63 e. Condoms are easy to get.
63 f. I’d have to rely on my partner’s cooperation.
63 g. Condoms make sex feel unnatural.
63 h. My partner would get angry.
63 i. It would be too much trouble to use a condom.
63 j.. My partner would think that I didn’t trust her.
63 k.. My partner would think that I play around.
63 l.. My sexual partner(s) has other sex partners.

64. The next set of questions is about HIV/AIDS. Here are some statements about how a person can get HIV/AIDS. Please check whether the statement is yes, no, or you don’t know the answer.

	Yes	No	Don’t Know
64 a.Can HIV/AIDS be spread by being sneezed on or coughed on?
64 b. Can HIV/AIDS be spread by eating in a restaurant where the cook has HIV/AIDS?
64 c.Can HIV/AIDS be spread by holding or shaking hands with someone who has HIV/AIDS?
64 d. Can HIV/AIDS be spread by mosquitoes or other insects?
64 e. Can HIV/AIDS be spread by using public toilets?

65. What do you think are the chances of you getting HIV/AIDS? Choose from very likely, likely, somewhat likely, to not all that likely.

	Very Likely	Likely	Somewhat Likely	Not At All Likely
65 a. What are the chances that you are infected with HIV now?
65 b. What are the chances that you will become infected in your lifetime?
65 c. What are the chances that your sex partners will get HIV?
65 d.What are the chances that things you have done have increased your chances of getting HIV?

66. Some people agree with these statements and other people do not. We are interested in your opinion, and want to know what you think about these statements. Please check how strongly you agree or disagree with the statement.

	Strongly Agree	Agree	Disagree	Strongly Disagree
66 a. If you had HIV, you would rather not know about it
66 b.If you had HIV, you wouldn’t want to infect anyone else
66 c.If you had HIV, people would reject you
66 d.Taking the HIV test would give you a sense of security
66 e.You are afraid to get an HIV test
66 f. Getting tested for HIV helps you stay healthy to care for your family and friends
66 g. You would be afraid to tell your sex partner that you got tested for HIV
66 h. You want to know if you have HIV, so you don’t give it to someone else
66 i. If you found out you had HIV, you couldn’t face your family
66 j. If you had HIV, you would want to tell your sex partner
66 k. It’s better not to know if you have HIV
66 l. Everyone should get an HIV test
	Strongly Agree	Agree	Disagree	Strongly Disagree
66 m. It’s not important to know if you have HIV, because fate will decide if you live or die
66 n. If you had HIV, you might get fired from your job or not be able to get a new job

67. Have you been tested for HIV?

a) 0=No, skip to Question 68 b)1=Yes.

68. How many times have you been tested? (Circle your answer).

a) Once b) Twice c) Three times or more

69. When was the last time you were tested? (Circle your answer).

a) Less than one month ago

b) 1-5 months ago

c) 6 months- 1 year ago

d) 1-5 years ago

e) More than 5 years ago

70. Were you offered an HIV test in jail/prison?

a) 0=No, skip to Question 70 or

b)1=Yes,

71. If yes, how were you offered the HIV test?

a) You were told you had to take an HIV test by jail/prison staff

b) You were given the option of taking an HIV test by jail/prison staff

c) You were given the option of taking an HIV test by health professionals visiting the jail/prison

d) You do not know if you were given an HIV test

72. Have you been tested since your release from jail or prison?

a) 0=No

b)1=Yes

73. Where did you take your last HIV test? (Circle your answer).

a) Hospital/ER

b) Free Clinic

c) Private doctor

d) Community organization_________________(write out)

e) STD clinic

f) Jail/Prison

g) Other _____________ (write out)

h) Don’t know

74. What information did you receive during your last HIV test visit? (Check all that apply).

	Yes	No	Don’t Know
74 a.My HIV test results were explained to me
74 b.I was told when I should take an HIV test again
74 c.I was provided information about HIV/AIDS

We are interested in why people take an HIV test. Are any of the following reasons why you took your last HIV test? (Please check No or Yes for each one).

75. Did you get HIV tested… No Yes

a) Because someone else suggested that you get

tested?  

b) Because you were worried that the last person

you had sex with might put you at risk for HIV?  

c) Because you had a drug use experience that

might have put you at risk for HIV?  

d) Because you were concerned you could give

HIV to someone else?  

e). Because a sex partner wanted you to?  

f) Because you wanted to get tested?  

g) Because you had to for a court ordered program,

the military, court order, jail or prison?  

76. Please check the answer that most matches how you currently feel about getting an HIV test:

(Check only one answer).

a)____ I am undecided/unsure about taking an HIV test

b)___ I don’t want to take an HIV test

c)____ I feel good about taking an HIV test

d)____ Does not apply to me

77. I am going to read you a list of reasons why some people have not been tested for HIV. Please tell me if the following are reasons why you have not been tested:

(Please check No or Yes for each one).

You have not taken an HIV test… No Yes

a) Because you were afraid of finding out you

that you were HIV-positive?  

b) Because you did not think you were at risk for  

getting HIV?

c) Because you did not want to think about

being HIV-positive?  

d) Because you did not have time?  

e) Because you had other things on your mind

besides HIV?  

f) Because you didn’t want people to think

you had HIV?  

g) Because you did not know where to get an  

HIV test?

h) None of the above

Since your release, have you seen or heard information about HIV testing in any of the following places? (Check No or Yes for each one).

78. Have you heard about HIV testing:

No Yes

a) On the radio?  

b) On TV?  

c) In a newspaper or magazine?  

d) At a sex/strip club?  

e) On a bus or at a bus stop?  

f) On a billboard?  

g) Neighborhood  

h) Community Agency  

i) Health fair  

j) Computer (internet)  

k) Other _______________  

(write out)

Thinking back to any HIV related information that you have seen or heard:

79. Were you able to connect to the information about HIV testing as a young Black man?

a) 0=No

b) 1=Yes

80. Were you able to connect to the information about HIV testing as a straight (heterosexual) man?

a) 0=No

b) 1=Yes

81. Were you able to connect to the information about HIV testing as someone who was recently arrested or released from jail/prison?

a) 0=No

b) 1=Yes

82. If you were in charge of developing a program to encourage HIV testing

among young Black men who have recently been released from jail/prison, what kinds of things would you do? (select top three choices)

1. Give mandatory testing

2. Develop a program where people can talk about their sexual experiences

3. Give rewards or free stuff to people who take an HIV test

4. Provide information about where to get tested for HIV

5. Show videos about how someone can get HIV

6. Show videos about how someone can prevent getting HIV

7. Show videos about the steps of taking an HIV test

8. Show videos of what life is like after someone becomes HIV-positive

9. Other ______________ (write out)

83. Who would be the best person to encourage Black men who have recently been released from jail/prison to take an HIV test? (Circle only one).

1. President Obama

2. Friends

3. Former gang member

4. Former drug dealer

5. Sexual partner

6. Family (parents)

7. HIV positive individual

8. Celebrities (which ones)___________________

9. Basketball Players (which ones)______________

10. Community member that is respected

11. Other (write out)__________________

84. Where would be the best place to give information about HIV testing to young Black men who have recently been released from jail/prison? (Circle only one)

1. Jail/prison facility

2. Community Programs for recently arrested or released men

3. Doctor’s office

4. Health clinic

5. Hospital

6. Billboard in the community

7. Community health fairs

8. In lyrics/songs

9. Radio stations

10. Television

11. Magazines (which ones) ___________________

12. Text messages

13. Internet/websites

14. Movie theaters at teen parties or clubs

15. Basketball tournaments

16. Entertainment events (e.g. music)

17. Other (write out)________________________

85. Where would be the best place to offer HIV testing for young Black men who have recently been released from jail/prison?

(Circle only one)

1. Jail/prison before and after release

2. Community programs for recently arrested or released men

3. Doctor’s office

4. Health clinic

5. Hospital

6. Community health fairs

7. Health van in the community

8. Youth programs (YMCA, Beacon programs)

9. At teen parties or clubs

10. Where Black men hang out (write out) __________

11. Other (write out)________________________________

You have almost reached the end of the survey. The last few questions are about your race, age, education and living arrangements. Please remember none of this information will be used to identify you or the answers you gave on the survey.

1. How old are you? (Circle your answer).

a) 18 b) 19 c) 20 d) 21 e) 22 f) 23 g) 24 h) 25 i) other

2. What is your race (Mark all that apply):

1. American Indian or Alaska Native

2. Asian

3. Black or African-American

4. Native Hawaiian or Other Pacific Islander

5. White

3. Are you multiracial (at least one of your parents is not Black)?

(Check your answer).

1. No_____

2. Yes_____

4. Were you born in the United States? (Check your answer)

1. ___ Yes b)__ No If no, how old were you when you came

to the U.S.? _____ (years)

5. Do you consider yourself to be:

1. Heterosexual/straight,

2. Gay,

3. Bisexual

4. Other _______________________

6. What’s the highest level of school you have completed? (Please circle only one).

1. Some High School

2. Finished High School (GED or diploma)

3. Finished Trade School (after high school)

4. Had Some College (less than 2 years)

5. Finished 2 Year College (Associates Degree)

6. Had more than 2 Years of College

7. 4 Year College Degree (Bachelors) or more

7. Are you going to school right now?

1. 0=No

2. 1=Yes. Please circle your status.

i) Full-time student

ii) Part-time student

8. Which describes your current work situation? (Check only one).

a) Working full time (40 hours per week)

b) Working regular part time job

c) Occasional odd jobs

d) Self-employed

e) Unemployed, looking for work

f) Unemployed, not looking for work

g) Unable to work

h) Other (please describe)_____________________________

9. What was is your monthly income from all sources?

a) Less than $500 per month

b) Less than $1000 per month

c) $1,000-$2,000 per month

d) $2,000-$4,000 per month

e) Over $4000 per month

f) Don’t know

10. Do you live in the same area now as before you were incarcerated? (Circle your answer).

1. 0=No

2. 1=Yes

11. Who do you currently live with? (Circle all that apply).

1. Mother

2. Father

3. Other Family (list)________________________

4. Wife/girlfriend/child’s mother

5. Friend

6. Treatment Center/Half-way house

7. Alone

8. Other (please describe) ___________

12. In the past 12 months, did you always have a regular place to live? (i.e., a regular place to live doesn’t change and is used nightly).

1. _____Yes

2. _____No If No, during the time you did not have a regular place to live, did you ever sleep in any of the following places?

	No	Yes
A friend or relative’s home
A park, an abandoned building, a car, on the street, or in a train or bus station
A shelter for homeless people
Other: (please list)

13. Which of the following best describes your relationship status? Please circle all that apply.

a) Married

b) Living with sexual partner

c) Committed relationship not living together

d) Divorced/Separate/Widowed

e) Single

f) Other__________________________________________

14. Do you have any children? (Circle your answer).

1. 0=No

b) 1=Yes. How many? _____

Before we end, I’d like to know what you thought about the survey, please write a couple comments about what you liked and disliked about the survey, as well as any questions you think we should have asked.

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

TIME END ____

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