Form 3 Baseline Survey

“Community-based Organization (CBO) Monitoring and Evaluation
Project of WILLOW (CMEP-WILLOW)”

Attachment 5a
Baseline Survey

Form Approved
OMB No. 0920-XXXX
Exp. Date: XX/XX/20XX

“Community-based Organization (CBO) Monitoring and Evaluation Project of WILLOW (CMEPWILLOW)”

Baseline Survey

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 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74,
Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

CMEP-WILLOW BASELINE DATA COLLECTION: General Information
(to be completed by staff)
The following section will be completed by CMEP-WILLOW staff.

G1. Client ID: ___ ___ ___ ___ [QDS QA Check: This number cannot be longer than 4 digits]
G2. Staff ID: ____________
G3. Data collection date: __ __/__ __/__ __ __ __ [QDS Instructions: drop-down menu]
(MM/DD/YYYY)
G4. Data collection site: __________________
G5. Data administered by: (Choose one)
Client
Provider (in-person)
Provider (on phone)
G6. Data collection method: (Choose one)
Laptop
Handheld device
Hard copy
G7. In the past 3 months, have you… (Choose all that apply)
Participated in a face-to-face group discussion about HIV prevention, HIV testing or safer sex
practices
Participated in an on-line discussion about HIV prevention, HIV testing, or safer sex practices
Received condoms or a safe sex kit
Received HIV Case Management services
Received Partner Services
Received written information about HIV/AIDS or STDs
Received other HIV prevention services (if yes, specify ____________________)
Has not participated in discussions or received materials related HIV/AIDS or STDs
Decline to answer

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G8. In the past 3 months, has the client participated in any HIV prevention interventions (e.g., CDC
effective behavioral interventions [EBIs])? (Choose one)
Yes
No [QDS Skip: Skip to G10]
Decline to answer
G9. If yes, which one(s)? (Choose all that apply) (Note: These interventions may be called a different name
at each agency)
Clear
Safe in the City
Connect
Safety Counts
Focus on Youth + IMPACT
SHIELD
Healthy Relationships
SIHLE
Holistic Health Recovery Program
SISTA
MIP
Sister to Sister
Partnership for Health
Street Smart
Popular Opinion Leader
Together Learning Choices
Project Start
VOICES/VOCES
PROMISE
WILLOW
RAPP
Other (specify): ___________________
RESPECT
Decline to answer
G10. *(H13) Recruitment source: How did the client become aware of WILLOW? (Choose one)
Agency
Health Communication / Public Information (e.g., flyer, poster, pamphlet)
Self
Partner
Friend and/or Family Members
Other (specify) ____________________________
Decline to answer
G11. *(H15) What is the name of the agency that referred the client?
___________________________________________________________
G12. *(H18) Which type of service or intervention did the agency above use to refer the client into
WILLOW? (Choose one)
Counseling and testing
Outreach
Health Communication/Public Info
Health Education/Risk Reduction
Partners Services
Intake/Screening
Comprehensive Risk Counseling Services
Other (specify) _________________________
Don’t know
___ Case Management
Decline to answer
___ Medical Services, specify___________

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CMEP-WILLOW DATA COLLECTION: Client-level Data
(to be completed by client)
Thank you for agreeing to participate in this survey. This survey is about your attitudes and behaviors
regarding sex and sexually transmitted diseases (STDs). Many of the questions are very personal. Your
answers will be kept private. Please answer as honestly and openly as you can. Do not hesitate to ask if
you don’t understand a question or need help figuring out dates. There are no right or wrong answers.
Let’s get started.

Demographics
The first set of questions asks you to provide some general information about yourself.
1. *(G112) What year were you born? ___ ___ ___ ___ [QDS Instructions: drop down menu]
2. How old are you? ______ [QDS QA Check: Respondents cannot be younger than 18 at time of data
collection] [QDS QA Check: Q2 = current year minus Q1 OR current year minus (Q1-1)]
3. *(G120) In which state do you currently live? (Choose one)
Florida

Massachusetts
New York
New Jersey
Connecticut
Other (Specify) _________________
4. *(G114) Are you: (Choose one)
Hispanic or Latino

Not Hispanic or Latino
Don’t know
Decline to answer
5. *(G116) What is your race? (Choose all that apply)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Don’t know *QDS QA Check: If any of the first 5 are checked, ‘Don’t know’ should not be enabled+
Decline to answer [QDS QA Check: If any of the first 5 are checked, ‘Decline to Answer’ should not
be enabled]

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6. *(G123) What was your sex at birth? (This is the biological sex on your birth certificate.) (Choose one)
Male
Female
Decline to answer
7. *(G124) How do you currently identify yourself? (Choose one)
Male
Female
Transgender – Male to female [QDS QA Check: If selected, include section about female partners]
Transgender – Female to male
Other (Specify if your gender is not one of the choices above): _________________
Decline to answer
8. Where were you born? (Choose one)
U.S. [QDS QA Check: If selected, then skip to Q10]
Other, specify: ________________________
Decline to answer
9. What year did you come to live in the U.S? _______
[QDS QA Check: Year must be greater than or equal to Q1 and less than or equal to current year]
Decline to answer
10. What is your first language?
English
Spanish
Portuguese
Creole
Other, specify______________
11. What is your current marital status? (Choose one)
Never married
Married
Separated
Divorced
Widowed
Decline to answer
12. What is the highest level of education that you have completed? (Choose one)
No schooling completed
Bachelor’s degree
th
8 grade or less
Post-graduate (Master’s-level degree)
Some high school
Post-graduate (Doctoral-level degree)
High school graduate/GED
Decline to answer
Some college (including technical school or training)

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13. Are you currently …? (Choose all that apply)
Employed for wages
Self-employed
Unemployed
Receiving unemployment benefits
Receiving public financial assistance (e.g., food stamps)
Receiving social security and/or disability
A homemaker
A student
Retired
Unable to work
Decline to answer

HIV & STD Testing, Medical Care, and Other HIV Services
The next set of questions is about your history with HIV and STD testing, medical care, and other HIV
services.
14. *(G204) Have you ever been tested for HIV? (Choose one)
Yes
No
Decline to answer
15. *(G205) What was the result of your last HIV test? (Choose one)
Positive
Negative
Don’t know
Decline to answer
16. When did you first test positive for HIV? ___ ___/___ ___ ___ ___
(If you do not remember the month or year, please provide your best estimate.)
(QDS Instructions: drop down boxes for month and year; QDS QA Check: year must be after 1985 and
month and year cannot be greater than current month and year. Options are available if client does
not remember the month and/or year, and these options are “grayed.”)
Don’t remember which month
Don’t remember which year
Decline to answer

17. *(G208) Have you seen a primary health care provider (doctor, nurse, etc.) for HIV-related care in the
last 6 months? (Choose one)
Yes
No
Decline to answer
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18. Have you been prescribed (anti-retroviral) medication for your HIV? (Choose one)
Yes
No [QDS Skip: If no, then skip to Q20]
Decline to answer
19. Have you been taking these HIV medications as directed over the last 6 months? (Choose one)
Yes
No
Decline to answer
20. In the last 12 months (1 year), has a health care provider told you that you have/had any of the
following? (Choose all that apply)
Gonorrhea (clap or drip)
Syphilis (“syphpox” or “bad blood”)
Chlamydia
No, I have not been diagnosed with a STD in the last 12 months [QDS Skip: Skip to Q22; QDS QA
Check: If any of the first 3 are checked, this response should not be enabled]
Decline to answer *QDS QA Check: If any of the first 4 are checked, ‘Decline to Answer’ should not
be enabled]
21. In the last 3 months (90 days), has a health care provider told you that you have/had any of the
following? (Choose all that apply)
Gonorrhea
Syphilis
Chlamydia
No, I have not been diagnosed with a STD in the last 3 months [QDS QA Check: If any of the first 3
are checked, this response should not be enabled]
Decline to answer *QDS QA Check: If any of the first 4 are checked, ‘Decline to Answer’ should not
be enabled]
22. Are you pregnant? (Choose one) [QDS QA Check: Do not ask if transgender male to female]
Yes
No [QDS Skip: Skip to Q24]
Don’t know [QDS Skip: Skip to Q24]
Decline to answer
23. Are you in prenatal care? (Choose one) [QDS QA Check: Do not ask if transgender male to female]
Yes
No
Decline to answer

Drug Use and Living Situation
The next of set questions are about your experience with drugs and your living situation.
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24. *(G211) In the last 12 months (1 year), have you injected drugs? (This includes illegal drugs and other
substances such as silicone, botox, hormones, etc.) (Choose one)
Yes
No [QDS Skip: Skip to Q29]
Decline to answer
25. *(G214) In the last 12 months (1 year), which drugs have you injected?
Heroin and cocaine together
Heroin alone
Cocaine alone
Crack
Amphetamines, speed, crystal, meth, ice
Other narcotic drugs, specify: __________
Hormones
Steroids
Silicone
Botox
Other medical substance: specify: _____________
Decline to answer *QDS QA Check: If any of the first 11 are checked, ‘Decline to Answer’ should not
be enabled]
26. In the last 12 months (1 year), have you shared needles, syringes or works? (That is, you let someone
else use your needles, syringes or works, or you borrowed someone else’s needles, syringes or works
to inject drugs.) (Choose one)
Yes
No [QDS Skip: If no, go to Q27 but skip Q28]
Decline to answer
27. In the last 3 months (90 days), have you injected drugs? (This includes illegal drugs and other
substances such as silicone, botox, hormones, etc.) (Choose one)
Yes
No [QDS Skip: Skip to Q29]
Decline to answer
28. In the last 3 months (90 days), how often did you share needles, syringes, or works? (That is, you let
someone else use your needles, syringes or works, or you borrowed someone else’s needles, syringes
or works to inject drugs.) (Choose one)
Never
Sometimes
Always
Decline to answer
29. In the last 3 months (90 days), were you homeless at any time? (That is, you slept in a shelter for
homeless people, on the streets, in a car, or another place not intended for sleeping. In other words,
you didn’t have a permanent address.) (Choose one)
Yes
No
Decline to answer

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30. In the last 3 months (90 days), were you in jail or prison for more than 24 hours? (Choose one)
Yes
No
Decline to answer

Sexual Risk Behaviors with Male Partners
The next series of questions will ask about sex you have had with a man. These questions are only
asking about vaginal or anal sex you have had with a man. They are NOT asking about oral sex
(giving/getting blow jobs or head).
Vaginal sex is when a man puts his penis in your vagina (hole in front). Anal sex is when a man puts his
penis into your anus (butt, hole in back). Condom use refers to the use of a male condom, unless a
female condom is mentioned.
Sex with Men in the Last 12 Months (1 year)
The next few questions ask about anal sex you’ve had with men over the last 12 months (1 year).
31. *(G211) In the last 12 months (1 year), have you had vaginal or anal sex with a man? (Choose one)
Yes
No [QDS Skip: If no, then only ask Q41-Q45, Q107-Q109, Q111-177]
Decline to answer

32. *(G212) In the last 12 months (1 year), did you have vaginal or anal sex with a man... (Choose all that
apply)
Without a condom
While you were drunk or high on drugs
So you could get drugs, money, a place to stay, clothing, or something else you needed
None of the above *QDS QA Check: If first 3 are checked, ‘None of the above’ not be allowed]
Decline to answer *QDS QA Check: If first 4 are checked, ‘Decline to Answer’ not be enabled]
33. *(G212) In the last 12 months (1 year), did you have sex with a man… (Choose all that apply)
Who has sex with another man
Who has sex with others so he could get drugs, money, a place to stay, clothing, or something else
he needed
Who was an injection drug user (Someone who injected illegal drugs or other substances such as
silicone, botox, hormones, etc.)
Whose was HIV-negative
Who was HIV-positive
Whose HIV status you don’t know
Who was a stranger (You do not know the person’s name and have no way to contact the person
again in the future)
Who was a hemophiliac, recipient of a blood transfusion, or a transplant recipient

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None of the above *QDS QA Check: If any of the first 7 are checked ‘Decline to Answer’ should not
be enabled]
Decline to answer *QDS QA Check: If any of the first 8 are checked ‘Decline to Answer’ should not
be enabled]
Sex with Men in the Last 3 months (90 days)
The next questions ask about vaginal or anal sex you’ve had with men over the last 3 months (90 days).
Some of the questions will ask you to report numbers. If your answer is none, please enter 0 (zero).
34. In the last 3 months (90 days), have you had vaginal or anal sex with a man? (Choose one)
Yes
No [QDS Skip: If no, then only ask Q41-Q45, Q107-109, Q111-177]
Decline to answer

35. In the last 3 months (90 days), how many men have you had vaginal or anal sex with? (Choose one)
______# partners [QDS QA Check: If response = 0 prompt respondent that they answered Yes in Q34 to
having vaginal or anal sex with a male in the last 3 months; QDS QA Check: If Q35 ≥ 46 ask the respondent to
confirm]
Decline to answer

36. In the last 3 months (90 days), how many times have you had vaginal or anal sex with a man?
(Choose one)
______# times *QDS QA Check: Q36 ≥ Q35. If no, then tell respondent that the number of times must be
greater than or equal to the number of partners and have them verify Q35 and Q36; QDS QA Check: If
response = 0 prompt respondent that they answered Yes in Q34 to having anal sex with a male in the last 3
months]
Decline to answer

37. Of the (#) [QDS Instructions: Populate with Q36 # response] times you had vaginal or anal sex with a
man during the last 3 months, how many times did you use a condom? (Choose one)
______ # times *QDS QA Check: Q37 ≤ Q36. If no, then tell respondent that the number of times they used a
condom must be less than or equal to the number of times they had sex and have them verify Q36 and Q37;
QDS QA Skip: If Q37 = Q36 or Q37 = 0, skip (do not ask) Qs 40,47,49,51,53,55,57,59,61,63,65,67,105,or 106]
Decline to answer

38. In the last 3 months (90 days), when you had vaginal or anal sex with a man, how often were you
drunk or high on drugs? (Choose one)
Never [QDS Skip: Skip to Q41]
Less than half the time
Half the time
More than half the time
All the time
Decline to answer

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39. In the last 3 months (90 days), when you had vaginal or anal sex with a man while high or drunk,
which were you using? (Choose all that apply)
Amphetamines, meth, speed, crystal, ice or crank
Crack
Heroin (injected, smoked, or snorted)
Poppers (Amyl nitrate)
Painkillers (including Oxycontin, Percocet)
Downers (Valium, Ativan, Xanax)
Club drugs such as GHB (G), Ketamine (K)
Ecstasy (E)
Marijuana (pot)
Hallucinogens such as LSD (acid)
Cocaine (smoked, snorted, or injected)
Alcohol
Other: __________________
Decline to answer *QDS QA Check: If any of the first 13 are checked, ‘Decline to Answer’ should not be
enabled]

40. In the last 3 months (90 days), when you had vaginal or anal sex with a man while high or drunk,
how often did you use condoms? (Choose one)
Never
Sometimes
Always
Decline to answer

The next questions ask about vaginal and anal sex with your MALE primary/main and casual sexual
partners.
A primary/main partner is someone you have a special emotional connection with, live with, love,
and/or call your boyfriend/husband.
A casual partner is someone you have had sex with but do not consider to be a primary/main partner. A
casual partner may be someone you have had sex with one time or many times.
Some of the questions in this section will ask you to report numbers. If your answer is 0 (zero), please
enter 0 in the space provided.
41. Do you currently have a primary or main male partner? (Choose one)
Yes
No [QDS QA Skip: Skip to Q46]
Decline to answer
42. How long have you been with your current primary or main male partner? (Choose one)
Less than 6 months
6 months to 1 year
1 to 5 years
Longer than 5 years
Decline to answer

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43. Are you living with your primary or main male partner? (Choose one)
Yes
No
Decline to answer
44. Are you financially dependent on your primary or main male partner? (Choose one)
Yes
No
Decline to answer
45. Is your current primary or main male partner HIV-positive? (Choose one)
Yes
No
Don’t know
Decline to answer
46. In the last 3 months (90 days), how many of the (#) [QDS Instructions: Populate with Q35 # response]
men that you have had vaginal or anal sex with were primary/main partners? (Choose one)
______# primary/main partners [QDS QA Check: Q46 must be less than or equal to Q35. If not, then tell
client that the number of primary/main male partners must be less or equal to the total number of male
and ask them to confirm their answers to Q35 and Q46; QDS QA check If Q46 ≥ 10, refer respondent to the
definition of primary/main partner and ask them to confirm the number of primary/main partners; QDS QA
Check: If response = 0 skip to Q48]
Decline to answer

47. In the last 3 months (90 days), how often did you use condoms when having vaginal or anal sex with
your male primary/main partner(s)? (Choose one)
Never
Sometimes
Always
Decline to answer
48. In the last 3 months (90 days), how many of the (#) [QDS Instructions: Populate with Q #35 response]
men that you have had vaginal or anal sex with were casual partners? (Choose one)
______# casual partners (If 0, enter 0) [QDS QA Check: Q46 + Q48 = Q35. If no, tell client that the number
of primary/main partners plus the number of casual partners must equal the total number of male partners.
Ask client to confirm Q35, 46, and 48; QDS QA Check: If response = 0 skip to Q50]
Decline to answer

49. In the last 3 months (90 days), how often did you use condoms when having vaginal or anal sex with
your male casual partner(s)? (Choose one)
Never
Sometimes
Always
Decline to answer

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The next set of questions is about the characteristics of the male partners you’ve had vaginal or anal sex
with. Some of the questions will ask you to report numbers. If your answer is none, please enter 0
(zero) in the space provided.
50. In the last 3 months (90 days), did you have vaginal or anal sex with a male who had an HIV status
that was unknown to you? (Choose one)
Yes
No [QDS Skip: Skip to Q52]
Decline to answer

51. In the last 3 months (90 days), how often did you use condoms when you had a vaginal or anal sex
with your male partner(s) whose HIV status you didn’t or don’t know? (Choose one)
Never
Sometimes
Always
Decline to answer
52. In the last 3 months (90 days), did you have vaginal or anal sex with a male who was HIV-negative?
(Choose one)
Yes
No [QDS Skip: Skip to Q54]
Decline to answer

53. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your male partner(s) who was HIV-negative? (Choose one)
Never
Sometimes
Always
Decline to answer
54. In the last 3 months (90 days), did you have vaginal or anal sex with a male only one time? (That is, a
one-night stand.) (Choose one)
Yes
No [QDS Skip: Skip to Q56]
Decline to answer

55. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your male partner(s) who you had vaginal or anal sex with only one time? (Choose one)
Never
Sometimes
Always
Decline to answer

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56. In the last 3 months (90 days), did you have vaginal or anal sex with a male who was a stranger or
anonymous? (That is, you do not know their name and you have no way of contacting them.) (Choose
one)
Yes
No [QDS Skip: Skip to Q58]
Decline to answer

57. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your anonymous male partner(s)? (Choose one)
Never
Sometimes
Always
Decline to answer
58. In the last 3 months (90 days), did a male sex partner give you money, drugs, a place to stay,
clothing, or something else you needed in exchange for vaginal or anal sex? (Choose one)
Yes
No [QDS Skip: Skip to Q60]
Decline to answer

59. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with a man who gave you money, drugs, a place to stay, clothing, or something else you needed in
exchange for vaginal or anal sex? (Choose one)
Never
Sometimes
Always
Decline to answer
60. In the last 3 months (90 days), did you give a male sex partner money, drugs, a place to stay,
clothing, or something else they needed in exchange for vaginal or anal sex? (Choose one)
Yes
No [QDS Skip: Skip to Q62]
Decline to answer

61. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your male partner(s) who you gave money, drugs, a place to stay, clothing, or something else
they needed in exchange for vaginal or anal sex? (Choose one)
Never
Sometimes
Always
Decline to answer

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62. In the last 3 months (90 days), did you have vaginal or anal sex with a male who you knew was an
injection drug user? (That is, they injected illegal drugs or other substances such as silicone, botox,
hormones, etc.) (Choose one)
Yes
No [QDS Skip: Skip to Q64]
Decline to answer

63. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your male partner(s) who injected drugs? (Choose one)
Never
Sometimes
Always
Decline to answer
64. In the last 3 months (90 days), did you have vaginal or anal sex with a male who you knew had spent
more than 24 hours in jail?
Yes
No [QDS Skip: Skip to Q66]
Decline to answer

65. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your male partner(s) who had spent more than 24 hours in jail? (Choose one)
Never
Sometimes
Always
Decline to answer
66. In the last 3 months (90 days), did you have vaginal or anal sex with a male who had a STD like
syphilis (syphpox), Chlamydia, or gonorrhea (clap)? (Choose one)
Yes
No [QDS Skip: Skip to Q105 unless Male to Female Transgender, then skip to Q68]
Decline to answer

67. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your male partner(s) who had syphilis, Chlamydia, or gonorrhea? (Choose one)
Never
Sometimes
Always
Decline to answer

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Sexual Risk Behaviors with Female Partners
[QDS Check: This section is only for Male to Female Transgender]
The next series of questions will ask about sex you have had with a woman. These questions are only
asking about vaginal or anal sex you have had with a woman. They are NOT asking about oral sex
(giving/getting blow jobs or head).
Vaginal sex is when you put a penis in a vagina (hole in front). Anal sex is when you puts a penis into an
anus (butt, hole in back). Condom use refers to the use of a male condom, unless a female condom is
mentioned.
Sex with Women in the Last 12 Months (1 year)
The next few questions ask about anal sex you’ve had with women over the last 12 months (1 year).
68. *(G211) In the last 12 months (1 year), have you had vaginal or anal sex with a woman? (Choose one)
Yes
No [QDS Skip: If no, then only ask Q78-Q82, Q107-109, Q111-177]
Decline to answer

69. *(G212) In the last 12 months (1 year), did you have vaginal or anal sex with a woman... (Choose all
that apply)
Without a condom
While you were drunk or high on drugs
So you could get drugs, money, a place to stay, clothing, or something else you needed
None of the above *QDS QA Check: If first 3 are checked, ‘None of the above’ not be allowed]
Decline to answer *QDS QA Check: If first 4 are checked, ‘Decline to Answer’ not be enabled]
70. *(G212) In the last 12 months (1 year), did you have sex with a woman… (Choose all that apply)
Who has sex with others so she could get drugs, money, a place to stay, clothing, or something else
he needed
Who was an injection drug user (Someone who injected illegal drugs or other substances such as
silicone, botox, hormones, etc.)
Whose was HIV-negative
Who was HIV-positive
Whose HIV status you don’t know
Who was a stranger (You do not know the person’s name and have no way to contact the person
again in the future)
Who was a hemophiliac, recipient of a blood transfusion, or a transplant recipient
None of the above *QDS QA Check: If any of the first 7 are checked ‘None of the above’ should not
be enabled]
Decline to answer [QDS QA Check: If any of the first 8 are checked ‘Decline to Answer’ should not
be enabled]

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Sex with Women in the Last 3 months (90 days)
The next questions ask about vaginal or anal sex you’ve had with women over the last 3 months (90
days). Some of the questions will ask you to report numbers. If your answer is none, please enter 0
(zero).
71. In the last 3 months (90 days), have you had vaginal or anal sex with a woman? (Choose one)
Yes
No [QDS Skip: If no, then only ask Q78-Q82, Q107-109, Q111-177]
Decline to answer

72. In the last 3 months (90 days), how many women have you had vaginal or anal sex with? (Choose
one)
______# partners [QDS QA Check: If response = 0 prompt respondent that they answered Yes in Q71 to
having vaginal or anal sex with a female in the last 3 months; QDS QA Check: If Q72 ≥ Q83 ask the
respondent to confirm]
Decline to answer

73. In the last 3 months (90 days), how many times have you had vaginal or anal sex with a woman?
(Choose one)
______# times [QDS QA Check: Q73 ≥ Q72. If no, then tell respondent that the number of times must be
greater than or equal to the number of partners and have them verify Q72 and Q73; QDS QA Check: If
response = 0 prompt respondent that they answered Yes in Q71 to having anal sex with a female in the last
3 months]
Decline to answer

74. Of the (#) [QDS Instructions: Populate with Q73 # response] times you had vaginal or anal sex with a
woman during the last 3 months, how many times did you use a condom? (Choose one)
______ # times [QDS QA Check: Q74 ≤ Q73. If no, then tell respondent that the number of times they used a
condom must be less than or equal to the number of times they had sex and have them verify Q73 and Q74;
QDS QA Skip: If Q74 = Q73 or Q74 = 0, skip (do not ask) Qs 77, 84, 86, 88, 90, 92, 94, 96, 98, 100, 102, 104,
105, or 106]
Decline to answer

75. In the last 3 months (90 days), when you had vaginal or anal sex with a woman, how often were you
drunk or high on drugs? (Choose one)
Never [QDS Skip: Skip to Q78]
Less than half the time
Half the time
More than half the time
All the time
Decline to answer

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76. In the last 3 months (90 days), when you had vaginal or anal sex with a woman while high or drunk,
which were you using? (Choose all that apply)
Amphetamines, meth, speed, crystal, ice or crank
Crack
Heroin (injected, smoked, or snorted)
Poppers (Amyl nitrate)
Painkillers (including Oxycontin, Percocet)
Downers (Valium, Ativan, Xanax)
Club drugs such as GHB (G), Ketamine (K)
Ecstasy (E)
Marijuana (pot)
Hallucinogens such as LSD (acid)
Cocaine (smoked, snorted, or injected)
Alcohol
Other: __________________
Decline to answer *QDS QA Check: If any of the first 13 are checked, ‘Decline to Answer’ should not be
enabled]

77. In the last 3 months (90 days), when you had vaginal or anal sex with a woman while high or drunk,
how often did you use condoms? (Choose one)
Never
Sometimes
Always
Decline to answer

The next questions ask about vaginal and anal sex with your FEMALE primary/main and casual sexual
partners.
A primary/main partner is someone you have a special emotional connection with, live with, love,
and/or call your girlfriend/wife.
A casual partner is someone you have had sex with but do not consider to be a primary/main partner. A
casual partner may be someone you have had sex with one time or many times.
Some of the questions in this section will ask you to report numbers. If your answer is 0 (zero), please
enter 0 in the space provided.
78. Do you currently have a primary or main female partner? (Choose one)
Yes
No [QDS QA Skip: Skip to Q83]
Decline to answer
79. How long have you been with your current primary or main female partner? (Choose one)
Less than 6 months
6 months to 1 year
1 to 5 years
Longer than 5 years
Decline to answer

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80. Are you living with your primary or main female partner? (Choose one)
Yes
No
Decline to answer
81. Are you financially dependent on your primary or main female partner? (Choose one)
Yes
No
Decline to answer
82. Is your current primary or main female partner HIV-positive? (Choose one)
Yes
No
Don’t know
Decline to answer
83. In the last 3 months (90 days), how many of the (#) [QDS Instructions: Populate with Q72 # response]
women that you have had vaginal or anal sex with were primary/main partners? (Choose one)
______# primary/main partners [QDS QA Check: Q83 must be less than or equal to Q72. If not, then tell
client that the number of primary/main female partners must be less or equal to the total number of
females and ask them to confirm their answers to Q72 and Q83; QDS QA check If Q83 ≥ 10, refer respondent
to the definition of primary/main partner and ask them to confirm the number of primary/main partners;
QDS QA Check: If response = 0 skip to Q85]
Decline to answer

84. In the last 3 months (90 days), how often did you use condoms when having vaginal or anal sex with
your female primary/main partner(s)? (Choose one)
Never
Sometimes
Always
Decline to answer
85. In the last 3 months (90 days), how many of the (#) [QDS Instructions: Populate with Q2 #72
response] women that you have had vaginal or anal sex with were casual partners? (Choose one)
______# casual partners (If 0, enter 0) [QDS QA Check: Q83 + Q85 = Q72. If no, tell client that the number
of primary/main partners plus the number of casual partners must equal the total number of female
partners. Ask client to confirm Q72, Q83, and Q85; QDS QA Check: If response = 0 skip to Q87]
Decline to answer

86. In the last 3 months (90 days), how often did you use condoms when having vaginal or anal sex with
your female casual partner(s)? (Choose one)
Never
Sometimes
Always
Decline to answer

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The next set of questions is about the characteristics of the female partners you’ve had vaginal or anal
sex with. Some of the questions will ask you to report numbers. If your answer is none, please enter 0
(zero) in the space provided.
87. In the last 3 months (90 days), did you have vaginal or anal sex with a female who had an HIV status
that was unknown to you? (Choose one)
Yes
No [QDS Skip: Skip to Q89]
Decline to answer

88. In the last 3 months (90 days), how often did you use condoms when you had a vaginal or anal sex
with your female partner(s) whose HIV status you didn’t or don’t know? (Choose one)
Never
Sometimes
Always
Decline to answer
89. In the last 3 months (90 days), did you have vaginal or anal sex with a female who was HIV-negative?
(Choose one)
Yes
No [QDS Skip: Skip to Q91]
Decline to answer

90. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your female partner(s) who was HIV-negative? (Choose one)
Never
Sometimes
Always
Decline to answer
91. In the last 3 months (90 days), did you have vaginal or anal sex with a female only one time? (That is,
a one-night stand.) (Choose one)
Yes
No [QDS Skip: Skip to Q93]
Decline to answer

92. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your female partner(s) who you had vaginal or anal sex with only one time? (Choose one)
Never
Sometimes
Always
Decline to answer

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93. In the last 3 months (90 days), did you have vaginal or anal sex with a female who was a stranger or
anonymous? (That is, you do not know their name and you have no way of contacting them.) (Choose
one)
Yes
No [QDS Skip: Skip to Q95]
Decline to answer

94. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your anonymous female partner(s)? (Choose one)
Never
Sometimes
Always
Decline to answer
95. In the last 3 months (90 days), did a female sex partner give you money, drugs, a place to stay,
clothing, or something else you needed in exchange for vaginal or anal sex? (Choose one)
Yes
No [QDS Skip: Skip to Q97]
Decline to answer

96. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with a female who gave you money, drugs, a place to stay, clothing, or something else you needed in
exchange for vaginal or anal sex? (Choose one)
Never
Sometimes
Always
Decline to answer
97. In the last 3 months (90 days), did you give a female sex partner money, drugs, a place to stay,
clothing, or something else they needed in exchange for vaginal or anal sex? (Choose one)
Yes
No [QDS Skip: Skip to Q99]
Decline to answer

98. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your female partner(s) who you gave money, drugs, a place to stay, clothing, or something else
they needed in exchange for vaginal or anal sex? (Choose one)
Never
Sometimes
Always
Decline to answer

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99. In the last 3 months (90 days), did you have vaginal or anal sex with a female who you knew was an
injection drug user? (That is, they injected illegal drugs or other substances such as silicone, botox,
hormones, etc.) (Choose one)
Yes
No [QDS Skip: Skip to Q101]
Decline to answer

100. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your female partner(s) who injected drugs? (Choose one)
Never
Sometimes
Always
Decline to answer
101. In the last 3 months (90 days), did you have vaginal or anal sex with a female who you knew had
spent more than 24 hours in jail?
Yes
No [QDS Skip: Skip to Q103]
Decline to answer

102. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your female partner(s) who had spent more than 24 hours in jail? (Choose one)
Never
Sometimes
Always
Decline to answer
103. In the last 3 months (90 days), did you have vaginal or anal sex with a female who had a STD like
syphilis (syphpox), Chlamydia, or gonorrhea (clap)? (Choose one)
Yes
No [QDS Skip: Skip to Q105]
Decline to answer

104. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your female partner(s) who had syphilis, Chlamydia, or gonorrhea? (Choose one)
Never
Sometimes
Always
Decline to answer

Condom Use
This section will ask you about your experience using condoms when you were having vaginal or anal
sex.

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105. In the last 3 months (90 days), how often did the male condom break or slip off during sex while
your partner was pulling out? (Choose one)
Never
Sometimes
All the time
Don’t know
Decline to answer

106. In the last 3 months (90 days), how often did you use the male condom after you had started
having sex or take the condom off before you had finished having sex? (Choose one)
Never
Sometimes
All the time
Don’t know
Decline to answer

107. Did you use a male condom the last time you had vaginal or anal sex? (Choose one)
Yes
No
Decline to answer
108. Do you plan to use a male condom the next time you have vaginal or anal sex? (Choose one)
Yes
No
Decline to answer
109. In the next 3 months, do you plan on using a male condom every time you have vaginal or anal sex?
(Choose one)
Yes
No
Decline to answer
110. In the last 3 months, did you attempt to use a female condom? (Choose one)
Yes
No
I don’t know what a female condom is
Decline to answer
111. In the next 3 months, do you plan on using a female condom? (Choose one)
Yes
No
Decline to answer

Attitudes and Beliefs Toward Condom Use
The following statements are about your attitudes toward using male condoms.
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112. My partner would get mad if I said we had to use a condom. (Choose one)
Yes
No
Decline to Answer

113. My partner would think I was having sex with another person if I said we had to use a condom.
(Choose one)
Yes
No
Decline to Answer

114. Condoms ruin the mood. (Choose one)
Yes
No
Decline to Answer

115. Sex doesn’t feel as good when you use a condom. (Choose one)
Yes
No
Decline to Answer

116. Sex with male condoms doesn’t feel natural. (Choose one)
Yes
No
Decline to Answer

117. Using condoms breaks up the rhythm of sex. (Choose one)
Yes
No
Decline to Answer

118. Using condoms would help build trust between my partner and me. (Choose one)
Yes
No
Decline to Answer

Self-Efficacy about Negotiation and Condom Use
The next questions ask about which kinds of situations are more difficult for you to use condoms when
you have sex with your partner. Even if the situation has not happened to you, try to imagine how you
would handle it if it ever happened.
119. Can you discuss condom use with your partner? (Choose one)
Yes
Maybe
No
Decline to answer
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120. Can you insist on condom use if your partner does not want to use one? (Choose one)
Yes
Maybe
No
Decline to answer

121. Can you stop and look for condoms when you are sexually aroused? (Choose one)
Yes
Maybe
No
Decline to answer

122. Can you insist on condom use every time you have sex even when you are under the influence of
drugs or alcohol? (Choose one)
Yes
Maybe
No
Decline to answer

123. Can you insist on condom use every time you have sex even when your partner is under the
influence of drugs? (Choose one)
Yes
Maybe
No
Decline to answer

124. Can you insist on condom use every time you have sex even if you or your partner uses another
method to prevent pregnancy? (Choose one)
Yes
Maybe
No
Decline to answer

125. Can you put a condom on your partner without spoiling the mood? (Choose one)
Yes
Maybe
No
Decline to answer

Self-Efficacy about Using Condoms
The next questions are about your confidence in using condoms. Even if you’ve never used condoms
before, think about how confident you would be if you were to use them in the future.
HOW CONFIDENT (SURE) ARE YOU THAT YOU COULD…
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126. Put a condom on a hard penis. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer

127. Unroll a condom down correctly on the first try. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer

128. Start over with a new condom if you placed it on the wrong way. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer

129. Unroll a condom fully to the base of the penis. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer

130. Squeeze air from the tip of a condom. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer

131. Take a male condom off without spilling the semen or cum. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer

132. Take a male condom off before partner loses their hard on. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer

133. Dispose of a used condom properly. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer

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134. Use lubricant with a condom. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer

Knowledge about HIV
The next questions are about your knowledge of HIV. Select “True” or “False.”
135. You have to take a test to know if you have HIV. (Choose one)
True
False
Decline to answer
136. A positive HIV test means that you have AIDS. (Choose one)
True
False
Decline to answer
137. Condoms can help protect you from transmitting or becoming infected with HIV. (Choose one)
True
False
Decline to answer
138. Having sex with someone who has HIV is the only way to get HIV. (Choose one)
True
False
Decline to answer
139. It is important to use a condom if both you and your partner have HIV. (Choose one)
True
False
Decline to answer
140. There are different types of HIV infections. (Choose one)
True
False
Decline to answer
141. Female condoms can stop you from getting HIV. (Choose one)
True
False
Decline to answer

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142. Having anal sex without a condom makes it easier to get HIV. (Choose one)
True
False
Decline to answer
143. Having a STD can make it easier to get HIV. (Choose one)
True
False
Decline to answer
144. Having a STD can make it harder to manage your HIV. (Choose one)
True
False
Decline to answer

Coping Style
There are a lot of things people can do when they have problems. These questions are about ways
you’ve dealt with your problems recently. Tell me how often you have done each of the below in the
last three months.
IN THE LAST 3 MONTHS, HAVE YOU…
145. Tried to keep your feelings to yourself? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
146. Tried to keep your feelings from interfering with other things too much? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
147. Tried to keep others from knowing how bad things are? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer

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148. Wished the situation would go away? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
149. Hoped a miracle would happen? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
150. Drank alcohol to deal with your problems? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
151. Had sex to deal with your problems? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
152. Used drugs (other than alcohol) to deal with your problems? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
153. Thought your problems were no big deal? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer

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154. Tried to forget about the whole thing? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
155. Gone on as if nothing had happened? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
156. Knew what had to be done, so you doubled your efforts to make things work? (Choose one.)
Never
A few times
Lots of times
All of the time
Decline to answer
157. Made a plan of action and followed it? (Choose one.)
Never
A few times
Lots of times
All of the time
Decline to answer
158. Just concentrated on what you had to do next? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
159. Talked to someone to find out more about the situation? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer

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160. Talked to someone about your feelings? (Choose one.)
Never
A few times
Lots of times
All of the time
Decline to answer
161. Talked to someone who could help do something about the problem? (Choose one.)
Never
A few times
Lots of times
All of the time
Decline to answer
162. Rediscovered what is important in life? (Choose one.)
Never
A few times
Lots of times
All of the time
Decline to answer
163. Saw the situation as an opportunity to change or grow in a good way? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer

Social Support Network
The next questions are about the people in your social network. Social network refers to the people
that you are connected to through different types of relationships, including your friends and family
members.
164. How many friends and/or family members loan you money, take care of you, or help you in an
emergency?
_________ (Enter total # of people, or 0 if none) [QDS Skip: If 0, skip to Q166]
Decline to answer

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165. How often do you talk to these people who loan you money, take care of you, or help you in an
emergency either on the phone or in-person? (Choose one)
About everyday
Twice a week
Once a week
Twice a month
Once a month or less
Decline to answer
166. How many friends and/or family members can you really talk to, rely on, and can understand you?
_________ (Enter total # of people, or 0 if none) [QDS Skip: If 0, skip to Q168]
Decline to answer
167. How often do you talk to these people whom you can really talk to, rely on, and who can understand you
either on the phone or in-person? (Choose one)
About everyday
Twice a week
Once a week
Twice a month
Once a month or less
Decline to answer
168. How many friends and/or or family members provide you with information or advice?
_________ (Enter total # of people, or 0 if none) [QDS Skip: If 0, skip to Q170]
Decline to answer
169. How often do you talk to these people who provide you with information or advice either on the phone
or in-person (Choose one)
About everyday
Twice a week
Once a week
Twice a month
Once a month or less
Decline to answer
170. How many friends and/or family members can you talk to about what it is like to have HIV?
_________ (Enter total # of people, or 0 if none) [QDS Skip: if 0, skip to Q172]
Decline to answer
171. How often do you talk to these people either on the phone or in-person? (Choose one)
About everyday
Twice a week
Once a week
Twice a month
Once a month or less
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Decline to answer
172. How many of the people in your life are domineering, try to tell you how to run your life, or give
unwanted advice?
_________ (Enter total # of people, or 0 if none) [QDS Skip: If 0, skip to Q174]
Decline to answer
173. How often do you talk to these people who are domineering, try to tell you how to run your life, or give
unwanted advice either on the phone or in-person? (Choose one)
About everyday
Twice a week
Once a week
Twice a month
Once a month or less
Decline to answer
174. How many friends and/or family members tell you that you should use a condom when you have sex?
_________ (Enter total # of people, or 0 if none) [QDS Skip: If 0, skip to Q176]
Decline to answer
175. How often do you talk on the phone or in-person to these people who tell you that should use a condom
when you have sex?
About everyday
Twice a week
Once a week
Twice a month
Once a month or less
Decline to answer
176. How many of your friends and/or family members tell you that you don’t need to wear a condom during
sex?
_________ (Enter total # of people)
Decline to answer [QDS Skip: If 0, skip to end of interview]
177. How often do you talk to these people either on the phone or in-person who tell you that you don’t need
to wear a condom during sex? (Choose one)
About everyday
Twice a week
Once a week
Twice a month
Once a month or less
Decline to answer

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