Form 4 180-day Follow-up Interview

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

Attachment 5c
180-Day Follow-up Survey

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

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

180-Day Follow-up Survey

Public reporting burden of this collection of information is estimated to average 18 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-RESPECT 180-DAY FOLLOW-UP DATA COLLECTION: General Information
(To be completed by staff)
The following section should be completed by CMEP-RESPECT 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. Survey 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, has the client… (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
Decline to answer
G8. In the past 3 months, has the client participated in any HIV intervention programs? (Choose one)
Yes
No [QDS Skip: Skip to Q1]
Decline to answer

1

G9. If yes, which one(s)? (Choose all that apply) (Note: These interventions may be called a different
name at each agency)
Clear
RAPP
Connect
RESPECT
d-up: Defend Yourself!
Safe in the City
Focus on Youth + IMPACT
Safety Counts
Healthy Relationships
SHIELD
Holistic Health Recovery Program
SIHLE
Many Men, Many Voices
SISTA
MIP
Sister to Sister
MPowerment
Street Smart
Nia
Together Learning Choices
Partnership for Health
VOICES/VOCES
Popular Opinion Leader
WILLOW
Project Start
Other (specify):
___________________
PROMISE
Decline to answer
G10. Did the client and counselor come up with a Risk Reduction Plan during Session 1?
Yes
No
Decline to answer

2

CMEP-RESPECT 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 need help figuring out dates or if you don’t understand a question. There are no right or wrong
answers. Let’s get started.

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.
1. *(G204) Have you ever been tested for HIV? (Choose one)
Yes
No [QDS Skip: Skip to Q6]
Decline to answer
2. When was your last HIV test?(If you can’t remember then take your best guess) (Choose one)
0-3 months ago
4-12 months ago
More than 12 months (1 year) ago
Decline to answer
3. *(G205) What was the result of your last HIV test? (Choose one)
Negative [QDS Skip: Skip to Q6]
Positive [QDS Skip: If Q3 is positive, skip (do not ask) Q122 and Q124]
Don’t know [QDS Skip: Skip to Q6]
Decline to answer
4. 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; year must be after 1985 and month and year cannot be greater than current month and
year)
Decline to answer
5. *(G208) Have you seen a primary health care provider (doctor, nurse, etc.) for HIV-related care in
the last 6 months? (Choose one)
Yes

3

No
Decline to answer
6. 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 any of these STDs 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]
7. In the last 3 months (90 days), have you had any of the following STD symptoms: (Choose all that
apply)
Discharge from your genitals
Pain when you urinate (pee)
A sore in your genital area
Rash or redness in your genital area
No, I have not had any of these symptoms in the last 3 months [QDS QA check: If any of the first
4 are checked this response 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]

Drug Use and Living Situation
The next of set questions are about your experience with drugs and your living situation. The
questions ask about your experiences over the last 3 months (90 days).
8. 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 Q10]
Decline to answer
9. In the last 3 months (90 days), when you injected drugs how often did you share needles, syringes
or works with someone else? (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
Less than half the time
Half the time

4

More than half the time
All the time
Decline to answer
10. 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, another place not intended for sleeping. In other words,
you didn’t have a permanent address) (Choose one)
Yes
No
Decline to answer
11. 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 MALE partners. These questions are
only asking about anal sex you have had with your male partners. They are NOT asking about oral sex
(giving/getting blow jobs or head).
Anal sex is when one partner puts their penis into the other partner’s anus (butt). The anal sex that
you have can be insertive, that is when you put your penis into someone’s anus (butt). This is often
called “topping.” Or it can be receptive, that is when your partner puts their penis in your anus (butt).
This is often called “bottoming.”
Sex with all Male Partners in the Last 3 months (90 days)
The next questions ask about anal sex you’ve had with your male partners over the last 3 months (90
days). Some of the questions will ask you to report numbers. If your answer is 0 (zero) please enter 0
in the space provided.
12. In the last 3 months (90 days), have you had anal sex with a male? (Choose one)
Yes
No [QDS Skip: Skip to Q48]
Decline to answer

5

13. In the last 3 months (90 days), how many male partners have you had anal sex with? (Choose one)
______# partners [QDS QA Check: If response = 0 prompt respondent that they answered Yes in
Q12 to having anal sex with a male in the last 3 months; QDS QA Check: If Q13 ≥ 45 ask the
respondent to confirm]
Decline to answer
14. In the last 3 months (90 days), how many times have you had anal sex with your male partner(s)?
(Choose one)
______# times [QDS QA Check: Q14 ≥ Q13. 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 Q13 and Q14; QDS
QA Check: If response = 0 prompt respondent that they answered Yes in Q12 to having anal sex
with a male in the last 3 months]
Decline to answer
15. Of the (#) [QDS Instructions: Populate with Q14 # response] times you had anal sex with your male
partner(s) during the last 3 months, how many times did you use a condom? (Choose one)
______ # times [QDS QA Check: Q15 ≤ Q14. 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 Q14 and Q15; QDS Skip: If Q15 = Q14 or Q15 = 0, skip (do not ask) Qs 17, 20, 23, 25, 27, 29,
31, 33, 35, 37, 39, 41, 43, 45, 47]
Decline to answer
16. In the last 3 months (90 days), when you had anal sex with your male partner(s) were you ever
the insertive partner? (That is, you put your penis in your partner’s anus *butt+.) (Choose one)
Yes
No [QDS Skip: Skip to Q18]
Decline to answer
17. In the last 3 months (90 days), when you had anal sex with your male partner(s) how often did
you use condoms when you were the insertive partner? (That is, you put your penis in your
partner’s anus *butt+.) (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
18. In the last 3 months (90 days), when you had anal sex with your male partner(s) were you ever
the receptive partner? (That is, your partner put his penis in your anus [butt].) (Choose one)
Yes

6

No [QDS QA Check: If Q16 = No, Q18 cannot equal No, If it does, ask the client to confirm that
for Q12 they responded that they had anal sex with a male sex partner in the last 3 months. Also
ask the client to confirm Q16 and Q18; QDS Skip: If Q16 = Yes and Q18 = No, skip to Q21]
Decline to answer
19. In the last 3 months (90 days), when you had anal sex with your male partner(s), how often were
you the receptive partner? (That is, your partner put his penis in your anus [butt].) (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time [QDS QA Check: If Q16 = No, Q18 must = All the time. If Q16 = No and Q19 does not
equal All the time, ask the client to confirm Q16; QDS QA Check: If Q16 = Yes and Q18 = Yes, this
value choice should not appear or not be enabled]
Decline to answer
20. In the last 3 months (90 days), when you had anal sex with your male partner(s) how often did
you use condoms when you were the receptive partner? (That is, your partner put his penis in your
anus [butt].) (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
21. In the last 3 months (90 days), when you had anal sex with your male partner(s) how often were
you drunk or high on drugs? (Choose one)
Never [QDS Skip: If never, skip to Q18]
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
22. In the last 3 months (90 days), when you had anal sex with your male partner(s) while high or
drunk, which were you using? (Choose all that apply)
Amphetamines, meth, speed, crystal, ice or crank
Heroin (injected, smoked or snorted)
Painkillers (including Oxycontin, Percocet)
Club drugs such as GHB (G), Ketamine (K)

7

Marijuana
Cocaine (smoked, snorted, or injected)
Crack
Poppers (Amyl nitrate)
Downers (Valium, Ativan, Xanax)
Ecstasy (E)
Hallucinogens such as LSD (acid)
Alcohol
Other: __________________
Decline to answer *QDS QA Check: If any of the first 13 are checked, ‘Decline to Answer’ should
not be enabled]
23. In the last 3 months (90 days), when you had anal sex with your male partner(s) while high or
drunk, how often did you use condoms? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
The next questions ask about anal sex with your male primary/main and casual partners.
A primary/main partner is someone you live with, have a special emotional connection with, love,
and/or call your boyfriend/girlfriend/husband/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.
24. In the last 3 months (90 days), how many of the (#) [QDS Instructions: Populate with Q13 #
response] men that you have had anal sex with were primary/main partners? (Choose one)
______# primary/main partners [QDS QA Check: Q24 must be less than or equal to Q13. 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 Q13 and Q24; QDS QA check: If Q24 ≥
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 Q26]
Decline to answer

8

25. In the last 3 months (90 days), how often did you use condoms when having anal sex with your
male primary/main partner(s)? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
26. In the last 3 months (90 days), how many of the (#) [QDS Instructions: Populate with Q13 #
response] men that you have had anal sex with were casual partners? (Choose one)
______# casual partners [QDS QA Check: Q24 + Q26 = Q13. 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 Q13, 24, and 26 QDS QA Check: If response = 0 skip to Q28]
Decline to answer
27. In the last 3 months (90 days), how often did you use condoms when having anal sex with your
male casual partner(s)? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
The next set of questions is about the characteristics of the male partners you’ve had anal sex with.
Some of the questions will ask you to report numbers. If your answer is 0 (zero) please enter 0 in the
space provided.
28. In the last 3 months (90 days), did you have anal sex with a male who had an HIV status that was
unknown to you? (Choose one)
Yes
No [QDS Skip: Skip to Q30]
Decline to answer
29. In the last 3 months (90 days), how often did you use condoms when you had anal sex with your
male partner(s) whose HIV status was unknown to you? (Choose one)
Never
Less than half the time
Half the time
More than half the time

9

All the time
Decline to answer
30. In the last 3 months (90 days), did you have anal sex with a male who you knew had an HIV status
that was different than yours? (Choose one)
Yes
No [QDS Skip: Skip to Q32]
Decline to answer
31. In the last 3 months (90 days), how often did you use condoms when you had anal sex with your
male partner(s) whose HIV status was different than yours? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
32. In the last 3 months (90 days), did you have anal sex with a male only one time? (That is, a onenight stand.) (Choose one)
Yes
No [QDS Skip: Skip to Q34]
Decline to answer
33. In the last 3 months (90 days), how often did you use condoms when you had anal sex with your
male partner(s) who you had anal sex with only one time? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
34. In the last 3 months (90 days), did you have anal sex with a male who was 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 Q36]
Decline to answer

10

35. In the last 3 months (90 days), how often did you use condoms when you had anal sex with your
anonymous male partner(s)? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
36. 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 anal sex? (Choose one)
Yes
No [QDS Skip: Skip to Q38]
Decline to answer
37. In the last 3 months (90 days), how often did you use condoms when you had anal sex with your
male partner(s) who gave you money, drugs, a place to stay, clothing or something else you
needed in exchange for anal sex? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
38. 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 to in exchange for anal sex? (Some common terms for
these men could include ‘sex workers’, ‘prostitutes’,’ hustlers’, etc.) (Choose one)
Yes
No [QDS Skip: Skip to Q40]
Decline to answer
39. In the last 3 months (90 days), how often did you use condoms when you had 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 anal sex? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer

11

40. In the last 3 months (90 days), did you have 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 Q42]
Decline to answer
41. In the last 3 months (90 days), how often did you use condoms when you had anal sex with your
male partner(s) who injected drugs? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
42. In the last 3 months (90 days), did you have anal sex with a male who you knew had spent more
than 24 hours in jail? (Choose one)
Yes
No [QDS Skip: Skip to Q44]
Decline to answer
43. In the last 3 months (90 days), how often did you use condoms when you had anal sex with your
male partner(s) who had spent more than 24 hours in jail? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
44. In the last 3 months (90 days), did you have anal sex with a male who had syphilis, Chlamydia or
gonorrhea? (Choose one)
Yes
No [QDS Skip: Skip to Q46]
Decline to answer
45. In the last 3 months (90 days), how often did you use condoms when you had anal sex with your
male partner(s) who had syphilis, Chlamydia or gonorrhea? (Choose one)
Never
Less than half the time

12

Half the time
More than half the time
All the time
Decline to answer
46. In the last 3 months (90 days), did you have anal sex with a male who you knew had one or more
of the following STD symptoms: discharge from the genitals, pain during urination (peeing), sores
in the genital area, rash or redness in the genital area? (Choose one)
Yes
No [QDS Skip: Skip to Q48]
Decline to answer
47. In the last 3 months (90 days), how often did you use condoms when you had anal sex with your
male partners who you knew had one or more of the following STD symptoms: discharge from the
genitals, pain during urination (peeing), sores in the genital area, rash or redness in the genital
area? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer

Sexual Risk Behaviors with Female Partners
The next series of questions will ask about sex you have had with FEMALE partners. These questions
are only asking about anal or vaginal sex you have had with your female partners. They are NOT
asking about oral sex (giving/getting blow jobs or head). Anal sex means putting your penis into
someone’s anus (butt).
Vaginal sex means putting your penis in someone’s vagina.
Sex with all Female Partners in the Last 3 months (90 day)
The next questions ask about anal or vaginal sex you’ve had with your female partners over the last 3
months (90 days). Some of the questions will ask you to report numbers. If your answer is 0 (zero)
please enter 0 in the space provided.
48. In the last 3 months (90 days), have you had anal OR vaginal sex with a female? (Choose one)
Yes
No [QDS Skip: Skip to Q81]

13

Decline to answer
49. In the last 3 months (90 days), how many female partners have you had anal OR vaginal sex with?
(Choose one)
______# partners [QDS QA Check: If response = 0 prompt respondent that they answered Yes in
Q48 to having anal or vaginal sex with a female in the last 3 month; QDS QA Check: If 49 ≥ 45 ask
the respondent to confirm]
Decline to answer
50. In the last 3 months (90 days), how many times have you had anal OR vaginal sex with your
female partner(s)?
______# times *QDS QA Check: Q50 ≥ Q49. 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 Q49 and Q50; QDS
QA Check: If response = 0 prompt respondent that they answered Yes in Q48 to having anal or
vaginal sex with a female in the last 3 months]
Decline to answer
51. Of the (#) [QDS Instructions: Populate with Q50 # response] times you had anal OR vaginal sex with
your female partner(s) during the last 3 months, how many times did you use a condom? (Choose
one)
_______# times (if 0, enter 0) [QDS QA Check: Q51 ≤ Q50. 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
Q50 and Q51; QDS QA Skip: If Q51 = Q50 or Q51=0, do not ask Qs 53, 55, 58, 60, 62, 64, 66, 68, 70,
72, 74, 76, 78, 80]
Decline to answer
52. In the last 3 months (90 days), have you had vaginal sex with your female partner(s)? (Choose
one)
Yes
No [QDS Skip: Skip to Q54]
Decline to answer
53. In the last 3 months (90 days), when you had vaginal sex with your female partner(s) how often
did you use condoms? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer

14

54. In the last 3 months (90 days), have you had anal sex with your female partner(s)? (Choose one)
Yes
No [QDS QA Check: If Q52 = No, Q54 = No. , ask client to confirm in Q48 that they have had anal
or vaginal sex with a female over the last 3 months. Also ask the client to confirm Q52.] [QDS QA
Check: If Q52 = Yes and Q54 = no, skip to Q68]
Decline to answer
55. In the last 3 months (90 days), when you had anal sex with your female partner(s) how often did
you use condoms? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
56. In the last 3 months (90 days), when you had anal OR vaginal sex with your female partner(s) how
often were you drunk or high on drugs? (Choose one)
Never [QDS Skip: Skip to Q59]
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
57. In the last 3 months (90 days), when you had anal OR vaginal sex with your female partner(s)
while high or drunk, which of the following substances were you using? (Choose all that apply)
Amphetamines, meth, speed, crystal, ice or crank
Heroin (injected, smoked or snorted)
Painkillers (including Oxycontin, Percocet)
Club drugs such as GHB (G), Ketamine (K)
Marijuana
Cocaine (smoked, snorted, or injected)
Crack
Poppers (Amyl nitrate)
Downers (Valium, Ativan, Xanax)
Ecstasy (E)
Hallucinogens such as LSD (acid)
Alcohol
Other: __________________

15

Decline to answer *QDS QA Check: If any of the first 13 are checked, ‘Decline to Answer’ should
not be enabled]
58. In the last 3 months (90 days), when you had anal OR vaginal sex with your female partner(s)
while high or drunk, how often did you use condoms? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
The next questions ask about anal or vaginal sex with your female primary/main and casual partners.
A primary/main partner is someone you live with, have a special emotional connection with, love,
and/or call your boyfriend/girlfriend/husband/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 ask you to report numbers. If your answer is 0 (zero) please
enter 0 in the space provided.
59. In the last 3 months (90 days), how many of the (#) [QDS Instructions: Populate with Q49 #
response] women that you have had anal OR vaginal sex with were primary/main partners?
(Choose one)
______# primary/main partners [QDS QA Check: Q59 must be less than or equal to Q49. If not,
then tell client that the number of primary/main female partners must be less or equal to the total
number of female and ask them to confirm their answers to Q49 and Q59; QDS QA Check: If Q59 ≥
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 Q61.]
Decline to answer
60. In the last 3 months (90 days), how often did you use condoms when having anal OR vaginal sex
with your female primary/main partner(s)? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer

16

61. In the last 3 months (90 days), how many of the (#) [QDS Instructions: Populate with Q49 #
response] women that you have had anal OR vaginal sex with were casual partners? (Choose one)
______# casual partners (If 0, enter 0) [QDS QA Check: Q59 + Q61 = Q49. If no, tell client that
the number of primary/main partners plus the number of casual partners must equal the total
number of total female partners. Ask client to confirm Q49, 59, and 61. QDS QA Check: If response
= 0 skip to Q63]
Decline to answer
62. In the last 3 months (90 days), how often did you use condoms when having anal OR vaginal sex
with your female casual partner(s)? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
The next set of questions is about the characteristics of the female partners you’ve had anal or vaginal
sex with.
Some of the questions will ask you to report numbers. If your answer is 0 (zero) please enter 0 in the
space provided.
63. In the last 3 months (90 days), did you have anal OR vaginal sex with a female who had an HIV
status that was unknown to you? (Choose one)
Yes
No [QDS Skip: Skip to Q65]
Decline to answer
64. In the last 3 months (90 days), how often did you use condoms when you had anal OR vaginal sex
with your female partner(s) whose HIV status was unknown to you? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer

17

65. In the last 3 months (90 days), did you have anal OR vaginal sex with a female who you knew had
an HIV status that was different than yours? (Choose one)
Yes
No [QDS Skip: Skip to Q67]
Decline to answer
66. In the last 3 months (90 days), how often did you use condoms when you had anal OR vaginal sex
with your female partner(s) whose HIV status was different than yours? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
67. In the last 3 months (90 days), did you have anal OR vaginal sex with a female only one time?
(That is, a one-night stand.) (Choose one)
Yes
No [QDS Skip: Skip to Q69]
Decline to answer
68. In the last 3 months (90 days), how often did you use condoms when you had anal OR vaginal sex
with your female partner(s) that you had anal OR vaginal sex with only one time? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
69. In the last 3 months (90 days), did you have anal OR vaginal sex with a female who was
anonymous? (Choose one) (That is, you do not know their name and you have no way of contacting
them.)
Yes
No [QDS Skip: Skip to Q71]
Decline to answer
70. In the last 3 months (90 days), how often did you use condoms when you had anal OR vaginal sex
with your anonymous female partner(s)? (Choose one)
Never
Less than half the time

18

Half the time
More than half the time
All the time
Decline to answer
71. 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 anal OR vaginal sex? (Choose one)
Yes
No [QDS Skip: Skip to Q73]
Decline to answer
72. In the last 3 months (90 days), how often did you use condoms when you had anal OR vaginal sex
with your female partner(s) that gave you money, drugs, a place to stay, clothing or something
else you needed in exchange for anal OR vaginal sex? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
73. 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 anal OR vaginal sex? (Choose one)
Yes
No [QDS Skip: Skip to Q75]
Decline to answer
74. In the last 3 months (90 days), how often did you use condoms with your female partner(s) that
you gave money, drugs, a place to stay, clothing or something else they needed in exchange for
anal OR vaginal sex? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
75. In the last 3 months (90 days), did you have anal OR vaginal sex with a female who you knew was
an injection drug user? (Choose one) (That is, they injected illegal drugs or other substances such as
silicone, botox, hormones, etc.)
Yes

19

No [QDS Skip: Skip to Q77]
Decline to answer
76. In the last 3 months (90 days), how often did you use condoms when you had anal OR vaginal sex
with your female partner(s) who injected drugs? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
77. In the last 3 months (90 days), did you have anal OR vaginal sex with a female who had syphilis,
Chlamydia or gonorrhea? (Choose one)
Yes
No [QDS Skip: Skip to Q79]
Decline to answer

78. In the last 3 months (90 days), how often did you use condoms when you had anal OR vaginal sex
with your female partner(s) who had syphilis, Chlamydia or gonorrhea? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
79. In the last 3 months (90 days), did you have anal OR vaginal sex with a female who you knew had
one or more of the following STD symptoms: discharge from the genitals, pain during urination
(peeing), sores in the genital area, rash or redness in the genital area? (Choose one)
Yes
No [QDS Skip: Skip to Q81]
Decline to answer
80. In the last 3 months (90 days), how often did you use condoms when you had anal OR vaginal sex
with your female partner(s) who you knew had one or more of the following STD symptoms:
discharge from the vagina, pain during urination (peeing), sores in the genital area, rash or
redness in the genital area? (Choose one)
Never
Less than half the time
Half the time

20

More than half the time
All the time
Decline to answer

Sexual Risk Behaviors with Transgender Partners
The next series of questions will ask about sex you have had with TRANSGENDER partners. These
questions are only asking about anal or vaginal sex you have had with your transgender partners.
They are NOT asking about oral sex (giving/getting blow jobs or head).
Anal sex is when one partner puts their penis into the other partner’s anus (butt). The anal sex that
you have can be insertive, that is when you put your penis into someone’s anus (butt). This is often
called “topping.” Or it can be receptive, that is when your partner puts their penis in your anus (butt).
This is often called “bottoming. “ Vaginal sex means putting your penis in someone’s vagina.
Sex with all Transgender Partners in the Last 3 Months (90 days)
The next questions ask about anal or vaginal sex you’ve had with your transgender partners over the
last 3 months (90 days). Some of the questions will ask you to report numbers. If your answer is 0
(zero) please enter 0 in the space provided.
81. In the last 3 months (90 days), have you had anal OR vaginal sex with a transgender partner?
(Choose one)
Yes
No [QDS Skip: Skip to Q120]
Decline to answer
82. In the last 3 months (90 days), how many transgender sex partners have you had anal OR vaginal
sex with? (Choose one)
______# partners [QDS QA Check: If response = 0 prompt respondent that they answered Yes in
Q81 to having anal or vaginal sex with a transgender in the last 3 months; QDS QA Check: If Q82 ≥
45 ask the respondent to confirm]
Decline to answer
83. In the last 3 months (90 days), how many times have you had anal OR vaginal sex with your
transgender partner(s)? (Choose one)
______# times [QDS Check: Q83 ≥ Q82. 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 Q82 and Q83; QDS
QA Check: If response = 0 prompt respondent that they answered Yes in Q81 to having anal or
vaginal sex with a transgender partner in the last 3 months]

21

Decline to answer
84. Of the (#) [QDS Instructions: Populate with Q14 # response] times you had anal OR vaginal sex with
your transgender partner(s) during the last 3 months, how many times did you use a condom?
______ # times [QDS QA Check: Q84 ≤ 83. If not, tell respondent that the number of times that
the number of times they used a condom must be less than or equal to the number of times they
have had sex and ask them to confirm Q83 and Q84; Q DS QA Skip: If Q84 = Q83 or Q84=0, skip (do
not ask) Qs 86, 89, 92, 95, 97, 99, 101, 103, 105, 107, 109, 111, 113, 115, 117, 119]
Decline to answer
85. In the last 3 months (90 days), have you had vaginal sex with your transgender partner(s)?
(Choose one)
Yes
No [QDS Skip: Skip to Q87]
Decline to answer
86. In the last 3 months (90 days), when you had vaginal sex with your transgender partner(s) how
often did you use
condoms? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
87. In the last 3 months (90 days), have you had anal sex with your transgender partner(s)? (Choose
one)
Yes
No [QDS QA Check: If Q85 = No, and Q87=No. If and Q85, ask client to confirm in Q81 that they
have had anal or vaginal sex with a transgender over the last 3 months. Also ask the client to
confirm Q85. Also ask the client to confirmQ85 and Q87; QDS Skip: If Q85 = Yes and Q87 = No, skip
to Q93]
Decline to answer
88. In the last 3 months (90 days), when you had anal sex with your transgender partner(s) were you
ever the insertive partner? (That is, you put your penis in your partner’s anus *butt+.) (Choose one)
Yes
No [QDS Skip: Skip to Q90]
Decline to answer

22

89. In the last 3 months (90 days), when you had anal sex with your transgender partner(s) how often
did you use condoms when you were the insertive partner? (That is, you put your penis in your
partner’s anus *butt+.) (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
90. In the last 3 months (90 days), when you had anal sex with your transgender partner(s) were you
ever the receptive partner? (That is, your partner put their penis in your anus [butt].) (Choose one)
Yes
No [QDS Check: If Q88 = No, and Q90 = No, ask the client to confirm that for Q87 they
responded that they had anal sex with a transgender partner in the last 3 months. Also ask the
client to confirm Q88 and Q90; QDS Skip: If Q88 = Yes and Q90 = No, skip to 93]
Decline to answer
91. In the last 3 months (90 days), when you had anal sex with your transgender partner(s) how often
were you the receptive partner? (That is, your partner put their penis in your anus [butt].) (Choose
one)
Less than half the time
Half the time
More than half the time
All the time [QDS QA Check: If Q88 = No, Q91 must = All the time. If Q88 = No and Q91 does not
equal All the time, ask the client to confirm Q88; QDS QA Check: If Q88 = Yes and Q90 = Yes, this
value choice should not appear or not be enabled]
Decline to answer
92. In the last 3 months (90 days), when you had anal sex with your transgender partner(s) how often
did you use condoms when you were the receptive partner? (That is, your partner put his penis in
your anus [butt].) (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer

23

93. In the last 3 months (90 days), when you had anal OR vaginal sex with your transgender partner(s)
how often were you drunk or high on drugs? (Choose one)
Never [QDS Skip: Skip to Q95]
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
94. In the last 3 months (90 days), when you had anal OR vaginal sex with your transgender partner(s)
while high or drunk, which of the following substances were you using? (Choose all that apply)
Amphetamines, meth, speed, crystal, ice or crank
Heroin (injected, smoked or snorted)
Painkillers (including Oxycontin, Percocet)
Club drugs such as GHB (G), Ketamine (K)
Marijuana
Cocaine (smoked, snorted, or injected)
Crack
Poppers (Amyl nitrate)
Downers (Valium, Ativan, Xanax)
Ecstasy (E)
Hallucinogens such as LSD (acid)
Alcohol
Other: __________________
Decline to answer *QDS QA Check: If any of the first 13 are checked, ‘Decline to answer’ should
not be enabled]
95. In the last 3 months (90 days), when you had anal OR vaginal sex with transgender partner(s)
while high or drunk, how often did you use condoms? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer

24

The next questions ask about anal or vaginal sex with your transgender primary/main and casual
partners.
A primary/main partner is someone you live with, have a special emotional connection with, love,
and/or call your boyfriend/girlfriend/husband/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 ask you to report numbers. If your answer is 0 (zero) please
enter 0 in the space provided.
96. In the last 3 months (90 days), how many of the (#) [QDS Instructions: Populate with Q82 #
response] transgender partners that you have had anal OR vaginal sex with were primary/main
partners? (Choose one)
______# primary/main partners [QDS QA check: Q96 must be less than or equal to Q82. If not,
tell client that the number of primary/male transgender partners must be less than or equal to the
total number of transgender and ask them to confirm their answers to Q82 and Q96; QDS check: If
Q96 ≥ 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 Q98]
Decline to answer
97. In the last 3 months (90 days), how often did you use condoms when having anal OR vaginal sex
with your transgender primary/main partner(s)? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
98. In the last 3 months (90 days), how many of the (#) [QDS Instructions: Populate with Q82 #
response] transgender partners that you have had anal OR vaginal sex with were casual partners?
(Choose one)
______# casual partners (If 0, enter 0) [QDS QA Check: Q96 + Q98 = Q82 If no, tell client that the
number of primary/main partners plus the number of casual partners must equal the total number
of total transgender partners. Ask client to confirm Q82, Q96, and Q100; Q DS QA Check: If
response = 0 skip to Q63]
Decline to answer

25

99. In the last 3 months (90 days), how often did you use condoms when having anal OR vaginal sex
with your transgender casual partner(s)? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
The next set of questions is about the characteristics of the transgender partners you’ve had anal or
vaginal sex with.
Some of the questions will ask you to report numbers. If your answer is 0 (zero) please enter 0 in the
space provided.
100. In the last 3 months (90 days), did you have anal OR vaginal sex with a transgender partner who
had an HIV status that was unknown to you? (Choose one)
Yes
No [QDS Skip: Skip to Q102]
Decline to answer
101. In the last 3 months (90 days), how often did you use condoms when you had anal OR vaginal
sex with your transgender partner(s) whose HIV status was unknown to you? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
102. In the last 3 months (90 days), did you have anal OR vaginal sex with a transgender partner who
you knew had an HIV status that was different than yours? (Choose one)
Yes
No [QDS Skip: Skip to Q104]
Decline to answer
103. In the last 3 months (90 days), how often did you use condoms when you had anal OR vaginal sex
with your transgender partner(s) whose HIV status was different than yours? (Choose one)
Never
Less than half the time
Half the time

26

More than half the time
All the time
Decline to answer
104. In the last 3 months (90 days), did you have anal OR vaginal sex with a transgender partner only
one time? (That is, a one-night stand.) (Choose one)
Yes
No [QDS Skip: Skip to Q106]
Decline to answer
105. In the last 3 months (90days), how often did you use condoms when you had anal OR vaginal sex
with your transgender partner(s) that you had anal OR vaginal sex with only one time? (Choose
one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
106. In the last 3 months (90 days), did you have anal OR vaginal sex with a transgender partner who
was 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 Q108]
Decline to answer
107. In the last 3 months (90 days), how often did you use condoms when you had anal OR vaginal sex
with your anonymous transgender partner(s)? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
108. In the last 3 months (90 days), did a transgender sex partner give you money, drugs, a place to
stay, clothing or something else you needed in exchange for anal OR vaginal sex? (Choose one)
Yes
No [QDS Skip: Skip to Q110]
Decline to answer

27

109. In the last 3 months (90 days), how often did you use condoms when you had anal OR vaginal
sex with your transgender partner(s) that gave you money, drugs, a place to stay, clothing or
something else you needed in exchange for anal OR vaginal sex? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
110. In the last 3 months (90 days), did you give a transgender sex partner money, drugs, a place to
stay, clothing or something else they needed in exchange for anal OR vaginal sex? (Some common
terms for these individuals could include ‘sex workers’, ‘prostitutes’, etc.) (Choose one)
Yes
No [QDS Skip: Skip to Q112]
Decline to answer
111. In the last 3 months (90 days), how often did you use condoms with transgender partner(s) that
you gave money, drugs, a place to stay, clothing or something else they needed in exchange for
anal OR vaginal sex? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
112. In the last 3 months (90 days), did you have anal OR vaginal sex a transgender partner who you
knew was an injection drug user? (That is, they injected illegal drugs or other substances such as
silicone, botox, insulin, hormones, etc.) (Choose one)
Yes
No [QDS Skip: Skip to Q114]
Decline to answer
113. In the last 3 months (90 days), how often did you use condoms when you had anal OR vaginal
sex with your transgender partner(s) who injected drugs? (Choose one)
Never
Less than half the time
Half the time
More than half the time

28

All the time
Decline to answer
114. In the last 3 months (90 days), did you have anal OR vaginal sex with a transgender partner who
you knew had spent more than 24 hours in jail? (Choose one)
Yes
No [QDS Skip: Skip to Q116]
Decline to answer
115. In the last 3 months (90 days), how often did you use condoms when you had anal OR vaginal
sex with your transgender partner(s) who had spent more than 24 hours in jail? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
116. In the last 3 months (90 days), did you have anal OR vaginal sex with a transgender partner who
had syphilis, Chlamydia or gonorrhea? (Choose one)
Yes
No [QDS Skip: Skip to Q118]
Decline to answer
117. In the last 3 months (90 days), how often did you use condoms when you had anal OR vaginal
sex with your transgender partner(s) who had syphilis, Chlamydia or gonorrhea? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
118. In the last 3 months (90 days), did you have anal OR vaginal sex with a transgender partner who
you knew had one or more of the following STD symptoms: discharge from the penis or vagina,
pain during urination (peeing), sores in the genital area, rash or redness in the genital area?
(Choose one)
Yes
No [QDS Skip: Skip to Q120]
Decline to answer

29

119. In the last 3 months (90 days), how often did you use condoms when you had anal OR vaginal sex
with your transgender partner(s) who you knew had one or more of the following STD symptoms:
discharge from the penis or vagina, pain during urination (peeing), sores in the genital area, rash
or redness in the genital area? (Choose one)
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer

Correct Condom Use
[QDS Skip: If Q30=0 and Q69=0 and Q105=0, skip to Q143]
This section will ask you about your experience using condoms over the last 3 months (90 days) when
you were having vaginal or anal sex.
120. In the last 3 months (90 days) how often did the condom break or slip off either during sex or
while you (or your partner) were pulling out? (Choose one)
Never
Sometimes
Always
Don’t know
Decline to answer
121. In the last 3 months (90 days), how often did you or your partner put the condom on after you
had started having sex or take the condom off before you had finished having sex? (Choose one)
Never
Sometimes
Always
Don’t know
Decline to answer

Perceived HIV Risk
The next set of questions is about how likely you think it is that you will get HIV/STDs or give
HIV/STDs to someone else.

30

122. What do you think is your chance of getting HIV/AIDS in the future if you do not use condoms
every time you have sex? (Choose one)
No chance
Unlikely
Likely
Certain to happen
Decline to answer
123. What do you think is your chance of getting an STD in the future if you do not use condoms
every time you have sex? (Choose one)
No chance
Unlikely
Likely
Certain to happen
Decline to answer
124. What do you think is your chance of getting HIV/AIDS in the future if you share needles,
syringes, or works when you inject drugs? (Choose one)
No chance
Unlikely
Likely
Certain to happen
Decline to answer
125. If you currently have a STD or were to get an STD, what do you think is your chance of giving an
STD to your partner(s) in the future if you do not use condoms every time you have sex? (Choose
one)
No chance
Unlikely
Likely
Certain to happen
Decline to answer
126. If you are currently HIV-positive or were to become HIV-positive, what do you think is your
chance of giving HIV/AIDS to your partner(s) in the future if you do not use condoms every time
you have sex? (Choose one)
No chance
Unlikely
Likely
Certain to happen
Decline to answer

31

127. If you are currently HIV-positive or were to become HIV-positive, what do you think is your
chance of giving HIV/AIDS to your partner(s) in the future if you share needles, syringes or works
when you inject drugs? (Choose the one answer that best describes your chance)
No chance
Unlikely
Likely
Certain to happen
Decline to answer

Risk Reduction Plan
Think back to your RESPECT session and any risk reduction plan that you made with your RESPECT
counselor/facilitator. The next set of questions is about this plan.
[QDS Instructions: If G10=No, then skip Q128-Q133]
128. Did you try to follow the Risk Reduction Plan that you developed with your RESPECT counselor?
(Choose one)
Yes
No
Decline to answer
129. In your opinion, were you successful in doing this plan? (Choose one)
Yes
No[QDS Skip: Skip to Q131]
Decline to answer
130. In your opinion, how likely is it that by doing this plan your risk for getting HIV or a STD was
reduced? (Choose one) [QDS Skip: Skip to Q133 which will be the last question of the survey]
Very unlikely
Unlikely
Likely
Very likely
Decline to answer
131. In your opinion, if you had successfully done this plan, how likely is it that this would have
reduced your risk for getting HIV or a STD? (Choose one) [QDS Skip: This question should only asked
for those clients who indicated that Q129 = ‘unsuccessful’+
Very unlikely
Unlikely

32

Likely
Very likely
Decline to answer
132. In your opinion, what was the main reason for not trying or not succeeding with this plan?
(Choose one) [QDS Skip: This question should only asked for those clients who indicated that Q129 =
‘unsuccessful’+
I forgot about it
I tried something else
It was too difficult
It did not seem important
It would not have reduced my risk
I was concerned about my partner’s reaction
My partner did not want to do it
I felt I needed skills, practice or experience to follow through with the plan
Some other reason
Decline to answer *QDS QA Check: If any of the first 9 are checked, ‘Decline to Answer’ should
not be enabled]
133. Which of these things made doing this plan difficult over the last 90 days? (Choose all that apply)
I felt I needed more skills to follow through with plan
It was hard to remember that I had made the plan
I needed to change the plan to make it work
It was uncomfortable for me
I needed someone to talk to about my plan
I had concerns about my partners reactions
My partner(s) were not cooperative or supportive
I did not have any difficulty with the plan
I had another barrier
Decline to answer *QDS QA Check: If any of the first 9 are checked, ‘Decline to Answer’ should
not be enabled]

33