Pre-Post Test Students

Cross-site Evaluation of the Minority Serving Institutions' HIV/AIDS Demonstration Initiative and Capacity Building Project

Pre- and Post- Tests 8-26

Pre-Post Test Students

OMB: 0990-0395

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Form Approved
OMB No. 0990Exp. Date __/__/20__

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0990. The time required to complete this information collection is estimated
to average (25 minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write
to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA
Reports Clearance Officer

A-1

The following statements are about sexually transmitted diseases or STDs. Please use the following scale to
select your response.
1
2
3
True
False
Don’t Know
3.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.

Birth control pills protect women against the AIDS virus.
Most people who have AIDS look sick.
Men are more susceptible (or likely) to get an STD infection than
women.
Having an STD can increase the risk of getting an HIV infection.
If a man has an STD, he will have noticeable symptoms on his
penis.
STDs can cause infertility, spontaneous abortions, or still births.
STDs can only be passed through open sores or lesions.
If a man pulls out before orgasm (cums), condoms do not need to
be used to protect against HIV.
Vaseline and other oils should be used to lubricate condoms.
Condoms cause men physical pain.
Most people who are infected with the AIDS virus look healthy.

1 2 3
1 2 3
1 2 3
1 2 3
1 2 3
1 2 3
1 2 3
1 2 3
1 2 3
1 2 3
1 2 3

4.
1
Strongly Disagree
a.
b.
c.
d.
e.

2
Disagree

3
Neither Agree or Disagree

My sexual experiences do not put me at risk for contracting HIV/AIDS.
There is a possibility that I may have HIV.
I may have had sex with someone who has HIV.
I am at risk for HIV/AIDS.
My sexual partner(s)’ behavior may place me at risk for HIV/AIDS.

4
Agree
1 2
1 2
1 2
1 2
1 2

5
Strongly
Agree
3 4 5
3 4 5
3 4 5
3 4 5
3 4 5

5. Please check all that apply. “I will not get HIV because…. “
_____I am now abstaining from sex
____I always use condoms when having sex
_____I have never had sex before
____I am in a monogamous relationship
_____I know that my partner and I have both tested negative _____I do think that I am at risk
_____other

A-2

PART 3: PEER NORMS
Thinking about your friends, who may include family members you consider friends, how many of
your friends do you think believes the statements below? Please use the scale below to select the best
response
1
2
3
4
5
None
Few
Some
Most
All
6.
a.
b.
c.
d.
e.
f.
g.
h.

It’s okay to have vaginal sex without a condom.
It’s okay to have anal sex without a condom.
It’s okay to be abstinent (choose not to have sex).
It’s okay to have sex with someone you just met.
Cheating on your boyfriend or partner is okay.
It’s safe to have sex when you are high on drugs or alcohol.
You don’t have to use a condom with someone you know well.
How many of your friends are having sex.

1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4

5
5
5
5
5
5
5
5

The following questions are about you and your current or most recent partner. Please use the following
scale to select the best response
1
Strongly Disagree

2
Disagree

3
Agree

4
Strongly Agree

7.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m
n
o
p
q

If I asked my partner to use a condom, he would get violent.
Most of the time we do what my partner wants to do.
My partner won’t let me wear certain clothes.
When my partner and I are together I am pretty quiet.
I feel trapped or stuck in my relationships.
My partner does what he wants even if I don’t want him to.
I am more committed to our relationship than my partner.
My partner always wants to know where I am.
My partner gets more out of the relationship than I do.
Having a partner at all times is important to me.
There are a lot of good men around to have a relationship with.
I tell my partner who he can spend time with.
No other man could love me the way my partner does.
My partner cares more about me than I do about him.
There is nothing I won’t do for my partner.
I have sex with no one else but my partner.
My partner and I have equal say about important decisions that
affect us.

A-3

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4

8. Thinking about how sure you are or are not please use the following scale to select the best response.
1
2
3
4
I definitely can’t say No
I can’t say No
I can Say NO
I Definitely Can Say NO
a.
b.
c.
d.
e.
f.
g.

That you would be able to say NO to having sex with someone you have
known for a few days or less?
That you would be able to say NO to having sex with someone you want to
date again?
That you would be able to say NO to having sex with someone who you
want to fall in love with you?
That you would be able to say NO to having sex with someone who is
pressuring you to have sex?
That you would be able to say NO to having sex with someone after you
have been drinking alcohol?
That you would be able to say NO to having sex with someone who refuses
to wear a condom?
That you would be able to say NO to having sex with someone who you
have had sex with before

PART 4: ABOUT YOUR SEXUAL BEHAVIOR
In this section, we would like to ask you some questions about your sexual relationships. Please remember,
all information that you provide is confidential.
The next few questions are about your beliefs about abstinence. Abstinence is when a person does NOT
have sexual intercourse for AT LEAST 2 months or more.
9. What is the longest amount of time you have gone without having sex in the past year? (Choose one)
____One month or less
____Four Months

______Two Months
______Five Months

______Three Months
_______Six Months or more

10. In the past 3 months, was there a time period when you didn’t have sex for two months or more in a
row?
_____ Yes

_____ No (Skip to Question 15)

11. What was your reason for NOT having sex? (Choose one)
____didn’t have a partner
_____My partner was away
____I was pregnant
_____I was sick
____My partner didn’t want to
_____Other:____________

____I was upset with my partner
____I didn’t want to

12. Thinking about the time you were abstinent, NOT having sex, please circle the best response
a. Did you perform oral sex on a guy
Yes No
b. Did you receive oral sex from a guy?
Yes No
c. Did you self-masturbate?
Yes No
d. Did you masturbate your male partner (jack your partner off)?
Yes No

A-4

13. Which statement best describes you (choose one)
___I am very interested in becoming abstinent
_____I am somewhat interested in becoming abstinent
___I am not interested in becoming abstinent
_____Refuse to answer
14. Which statement best describes your current or most recent boyfriend or partner (choose one)
___I think my partner is very interested in becoming abstinent
___I think my partner is somewhat interested in becoming abstinent
___I think my partner is not interested in becoming abstinent
___Don’t have a current sex partner
15. Have you ever had vaginal sex? Yes No (Skip to question 19)
16. If yes, thinking about the very last time you had vaginal sex (penis in vagina) did you use a condom to
prevent STD/HIV infection?
Yes
No
17. If yes to #15, thinking about the very last time you had vaginal sex (penis in vagina) did you use a
condom to prevent pregnancy?
Yes
No
Using the Scale below please circle the best response
1
2
3
Never
Rarely
Frequently

4
All of the Time

5
Not applicable (no
sex in 6 months)

18.
a.

In the past 3 months how often did you use a condom 1 2 3 4 5
(male or female) during vaginal sex

19. Have you ever performed oral sex on a man (mouth on penis)? Yes

No (skip to question 22)

20. If yes, thinking about the very last time did you use a latex barrier?

Yes

21. Using the scale above please circle the appropriate response
a. In the past 3 months how often did you use a latex 1 2 3 4 5
barrier when performing oral sex on a man (please
select one)
22. Have you ever had anal sex (penis in anus)?

Yes

No (skip to question 25)

23. If yes, thinking about the very last time, did your male partner use a condom? Yes
24. Using the previous scale please circle the best response
a. In the past 3 months how often did you use a latex 1 2 3 4 5
barrier when having anal sex?

A-5

The next few questions are about using condoms. Even if you have never used condoms, think about how
much of a problem it would be for you to do the following statements. Using the scale below, circle the best
response
1
2
3
4
5
None
Not Much
A Little
Some
A lot
25.
How much of a problem would it be for you to put a condom on a hard penis?
a.
1 2 3 4 5
b. How much of a problem would it be for you to unroll a condom down correctly 1 2 3 4 5
on the first try?
How much of a problem would it be for you to start over using a new condom if 1 2 3 4 5
c.
you placed it on the wrong way?
d. How much of a problem would it be for you to unroll a condom fully to the 1 2 3 4 5
base of a penis?
How much of a problem would it be for you to squeeze air from the tip of a 1 2 3 4 5
e.
condom?
How much of a problem would it be for you to take a condom off without 1 2 3 4 5
f.
spilling the semen?
How much of a problem would it be for you to take a condom off before your 1 2 3 4 5
g.
partner loses his erection?
h. How much of a problem would it be for you to dispose of a used condom?
1 2 3 4 5
How much of a problem would it be for you to use a water-based lubricant with 1 2 3 4 5
i.
a condom?
The next set of questions are about how you feel about condom use. Circle the appropriate answer:
1
Strongly Disagree

2
Somewhat disagree

3
Somewhat Agree

4
Strongly Agree

26.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.

Using a condom makes sex less enjoyable for me.
If I asked my partner to use a condom, he would think I am trying to protect our
health.
If I asked my partner to use a condom, he would get angry.
Using a condom makes sex less enjoyable for my partner.
If I asked my partner to use a condom, he would think that I am having sex with
other people.
If I asked my partner to use a condom, he would agree.
If my partner asked me to use a condom, I would get angry.
If my partner asked me to use a condom, I would think that he is having sex with
other people.
If my partner asked me to use a condom I would agree.
If I asked my partner to use a condom, he would get violent.
If my partner asked me to use a condom, I would think that he is trying to protect
our health.

A-6

1
1

2
2

3
3

4
4

1
1
1

2
2
2

3
3
3

4
4
4

1
1
1

2
2
2

3
3
3

4
4
4

1
1
1

2
2
2

3
3
3

4
4
4

Think about how hard it is for you to do each of the following with a current or most recent boyfriend or
main partner. Indicate how hard or easy it would be for you by selecting the number that corresponds to
your answer.
1
2
3
4
Very Hard
Hard
Easy
Very Easy
27.
a. How hard is it for you to ask how many sex partners he has had?
1 2 3 4
b. How hard is it for you to ask if he is having sex with you and other women?
1 2 3 4
c. How hard is it for you to ask if he has a STD?
1 2 3 4
d. How hard is it for you to ask if he has HIV?
1 2 3 4
e. How hard is it for you to ask if he would use a condom?
1 2 3 4
How
hard
is
it
for
you
to
demand
that
he
use
a
condom?
f.
1 2 3 4
g. How hard is it for you to refuse to have sex if he won’t wear a condom?
1 2 3 4
Answer the following questions based on the past 90 days referring to your current or most recent boyfriend
only. Use the following scale to circle the best response
1
2
3
4
Never
1-3 Times
4-6 Times
7 or more times
28.
a. How many times have you and your boyfriend or sex partner(s) talked about how 1 2 3 4
to prevent pregnancy?
b. How many times have you and your boyfriend or sex partner(s) talked about how 1 2 3 4
to use condoms?
c. How many times have you and your boyfriend or sex partner(s) talked about how 1 2 3 4
to prevent getting the AIDS virus?
d. How many times have you and your boyfriend or sex partner(s) talked about how 1 2 3 4
to prevent getting STDs?
e. How many times have you and your boyfriend or sex partner(s) talked about his 1 2 3 4
sexual history?
PART 5: OPINIONS & BELIEFS
Now, I would like to ask you some questions about your opinions and beliefs in different situations.
There is no right or wrong answer. We would like to know how you feel. Using the following scales,
please circle the answer that you most agree with.
29.
1
2
3
4
5
Much Greater

Slightly Greater

About the Same

a. Compared to other African American women, my chances
of experiencing a tragic event are………..…..
b. Compared to other African American women, my chances of
accidentally becoming pregnant are…..
c. Compared to other African American women, my chances of
experiencing positive life events are………
d. Compared to other African American women, my chances of
contracting a sexually transmitted disease are…………
e. Compared to other African American women, my chances of
contracting HIV are……

A-7

Slightly Less

Much Less

2 3 4

30. Do you have a religious affiliation/orientation? (e.g., Baptist, Methodist, Agnostic, etc.)
______No
_______ Yes, If yes please specify _______________
31.The following questions are about your beliefs as it relates to either religion and/or spirituality.
Please use the following scale to select the best response
1
2
3
4
5
Strongly Disagree
Disagree
Neutral
Agree
Strongly
Agree
a. Religion/Spirituality is in important to me.
1 2 3 4 5
b. My religious/spiritual beliefs do not have influence on my decision to have sex

2 3 4

c. I do not feel comfortable discussing my religious/spiritual beliefs with my partner(s)

2 3 4

d. My religious/spiritual beliefs influence my decision to not have sex

2 3 4

e. My decision to use or not use condoms is based on my religious/spiritual beliefs

2 3 4

f. Because of my religious/spiritual beliefs I feel bad when I have sex.

2 3 4

g. Because of my religious/spiritual beliefs I feel bad when I use contraception like birth
control pills
h. Because of my religious/spiritual beliefs I feel bad when I use condoms during sex.

2 3 4

i. My place of worship is not a place that I feel comfortable discussing issues related to sex 1

2 3 4

j. My place of worship understands the sexual pressures young women face today.

2 3 4

PART 6: BACKGROUND INFORMATION
32. How would you rate your HIV knowledge?
_____Poor ______ Fair _____ Average _____Good ______ Excellent
33. Have you ever been tested for HIV?
If yes, did you return for your results?

_________Yes
_________No
_______Yes __________No

If yes, were you tested within the past:
_______3 months
________9 months
_______6 months
________over a year ago
34. How likely are you to get an HIV test in the next 3 months?
_______Very unlikely ______Unlikely
_____Likely ______Very Likely
35. Are you currently trying to become pregnant?

_________ Yes

36. Have you visited a health clinic in the past 90 days? ________Yes

_________No
_________No

THANK YOU KINDLY FOR YOUR PARTICIPATION

A-8

That you would be able to say NO to having sex with someone you have known for a few
days or less?
That you would be able to say NO to having sex with someone you want to date again?
That you would be able to say NO to having sex with someone who you want to fall in love
with you?
That you would be able to say NO to having sex with someone who is pressuring you into
having sex.
That you would be able to say NO to having sex with someone after you have been drinking
alcohol
That you would be able to say NO to having sex with someone who refuses to wear a
condom?
That you would be able to say NO to having sex with someone who you have had sex with
before.

a.
b.
c.
d.
e.
f.
g.

1
1

2
2

3
3

4
4

How much of a problem would it be for you to unroll a condom down correctly on
the first try?
How much of a problem would it be for you to start over using a new condom if you
placed it on the wrong way?
How much of a problem would it be for you to unroll a condom fully to the base of a
penis?
How much of a problem would it be for you to squeeze air from the tip of a condom?
How much of a problem would it be for you to take a condom off without spilling
the semen?
How much of a problem would it be for you to take a condom off before your partner
loses his erection?
How much of a problem would it be for you to dispose of a used condom?
How much of a problem would it be for you to use a water-based lubricant with a
condom?

3 4 5

1
1

2
2

3 4 5
3 4 5

3 4 5

1
1

2
2

3 4 5
3 4 5

______ Excellent

8. How likely are you to get an HIV test in the next 3 months?
_______Very unlikely ______Unlikely _____Likely ______Very Likely

Form Approved
OMB No. 0990Exp. Date __/__/20__

Handout 1E

Session I Evaluation
Evaluation for:Session 1: Ethnic and Gender Pride

Please take a moment to rate how effective we were in presenting information to you
today.
Below are a number of statements. Please rate each statement on a scale from 15,
where "1" means we did a poor job and "5" means we did an excellent job.

Statements:

Rating ,

1.
2.
3.
4.
5.
6.

1 feel more pride in myself as an African American woman.
1 have a better understanding of the importance of personal values.
I feel I got a lot out of the in-class games/exercises we did today.
Any questions I had were clearly answered.
The handouts were helpful.
The group discussions were interesting and informative.
Overall, how would you rate the performance of the group leaders? Please circle
a number.

Overall, how would you rate today's session? Please circle a number.

How could this session be improved?

10. Any other comments?

Thank You, my SISTA!
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is
0990. The time required to complete this information collection is estimated to average (25 minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports

Form Approved
OMB No. 0990Exp. Date __/__/20__

Handout 2G

Session 2 Evaluation
Evaluation for Session 2: HIV/AIDS Education

!
"!

.;Staternents::R:'

Rating

'
+
7

$#%
*

##
4"

8;#

How could this session be improved? Any other comments?

Questions
continue on back of page.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0990. The time required to complete this information collection is estimated
to average (25 minutes) per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite
336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

A-1

8
F#

N F

Thank You, my SISTA!

A-2

Handout 3H

Session 3 Evaluation
Evaluation for;Session 3: HIV/AIDS Education

Rating
1.
2.
3.
4.
5.
6.

I am confident I can communicate more effectively.
I am confident I can start a discussion about condom use with my
partner.
I am confident I can apply the SISTAS Assertiveness Model in my life.
1 feel I got a lot out of the role-play situations.
Any questions 1 had were clearly answered.
The handouts were helpful.

Overall, how would you rate the performance of the group leaders? Please
circle a number.

Excellent

Poor
1
8.

Overall, how would you rate today's session? Please circle a number.

How could this session be improved? Any other comments? Questions continue on back of page.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is
0990. The time required to complete this information collection is estimated to average (25 minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports
Clearance Officer

11. As a result of last week's session, I made some positive changes in my life.

Yes

Did not attend last week's session.

If you checked yes, please describe below the changes you made.

Thank You, my SISTA!

Handout 4H

Session 4 Evaluation

Evaluation for Session 4• Behavioral Self-Management Training
Please take a moment to rate how effective we were in presenting information to you
today.
Below are a number of statements. Please rate each statement on a scale from 15,
where "1" means we did a poor job and "5" means we did an excellent job.

Rating
1.
2.
3.
4.
5.
6.

1 am confident I can communicate more effectively.
1 am confident I can start a discussion about condom use with my
partner.
I am confident I can apply the SISTAS Assertiveness Model in my life.
I feel I got a lot out of the role-play situations.
Any questions I had were clearly answered.
The handouts were helpful.
Overall, how would you rate the performance of the group leaders? Please circle
a number.

Overall, how would you rate today's session? Please circle a number.

Excellent
10
9.

How could this session be improved?

10.

Any other comments?

Questions continue on back of page.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is
0990. The time required to complete this information collection is estimated to average (25 minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s)
or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA,
200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

iT5r4-#

11. As a result of last week's session, I made some positive changes in my life.
Yes

Did not attend last week's session.

If you checked yes, please describe below the changes you made.

Thank You, my SISTA!

Questions continue on back of page.

Handout 5F

Session 5 Evaluation
Evaluation tar Session 5: Coping Skills

Rating
1.
2.
3.
4.
5.
6.
7.

1 feel I got a lot of the role-play situations about coping.
I am confident I can apply these coping skills in my life.
I have a better understanding of the effects of drugs and alcohol.
Any questions I had were clearly answered.
The handouts were helpful.
The group discussions were informative.
The review of materials we covered in earlier sessions of the SISTA
intervention was worthwhile.

Overall, how would you rate the performance of the group leaders? Please circle
a number.

Overall, how would you rate today's session? Please circle a number.

10.

Overall, how would you rate the SISTA intervention? Please circle a number_

Poor
1
11.

Excellent

Okay
6

How could Session 5 be improved?

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless
it displays a valid OMB control number. The valid OMB control number for this information collection is 0990. The
time required to complete this information collection is estimated to average (25 minutes) per response, including the time
to review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E,
Washington D.C. 20201, Attention: PRA Reports Clearance Officer

12. Any other comments?

13.

As a result of last week's session, I made same positive changes in my life.

Yes

Did not attend last week's session.

If you checked yes, please describe below the changes you made.

Thank You, my SISTA!

Form Approved
OMB No. 0990Exp. Date __/__/20__

6,67$35(7(6732677(67
,QVWUXFWLRQV
Please complete this form as honestly and thoroughly as possible. Your responses are very
important to us! Your answers will help us learn more about issues that affect African
American women like you and will also help us to make improvements and changes to
SISTA. Thank you for taking the time to complete this form. Please note that if you are
completing this survey for the first time (a pretest), you will be asked to fill out additional
copies of the form after SISTA Session 5 or during your booster sessions (a posttest).

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0990. The time required to complete this
information collection is estimated to average (25 minutes) per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health
& Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201,
Attention: PRA Reports Clearance Officer

6,67$(YDOXDWLRQ)LHOG*XLGH6HSWHPEHU
A-1

7KHIROORZLQJVWDWHPHQWVDUHDERXW\RXUDWWLWXGHVWRZDUGXVLQJFRQGRPV

,16758&7,216Please indicate how much you agree or disagree with each statement by putting

a check mark (9) under your choice.
6WURQJO\
'LVDJUHH

My main partner would get mad if I said we had to
use a male condom.

Male condoms ruin the mood.

Sex doesn’t feel as good when you use a condom.

My main partner would think I was having sex with
another person if I said we had to use a condom.

Using male condoms would help build trust
between my main partner and me.

Sex with condoms doesn’t feel natural.

Using male condoms breaks up the rhythm of sex.

'LVDJUHH

$JUHH

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$JUHH

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XVHFRQGRPVZKHQ\RXKDYHVH[ZLWK\RXUPDLQSDUWQHU(YHQLIWKHVLWXDWLRQKDVQRW
KDSSHQHGWR\RXWU\WRLPDJLQHKRZ\RXZRXOGKDQGOHLWLILWHYHUKDSSHQHG

,16758&7,216 Place a check mark (9) under your choice.
'HILQLWHO\
1R

Can you discuss condom use with your main
partner?

Can you insist on condom use if your main partner
does not want to use one?

10. Can you stop and look for condoms when you are
sexually aroused?
11. Can you insist on condom use every time you have
sex even when you are under the influence of
drugs?
12. Can you insist on condom use every time you have
sex even when your main partner is under the
influence of drugs?
13. Can you put a condom on your main partner without
spoiling the mood?
14. Can you insist on condom use every time you have
sex even if you or your main partner uses another
method to prevent pregnancy?

6,67$(YDOXDWLRQ3ODQ'UDIW
A-2

3UREDEO\
1R

3UREDEO\

Nia-Appendix D: Pre-Intervention Assessment Survey
A-4

22.
Based on your behavior in the past 2 months, what do you think is your
risk for getting the virus that causes AIDS? (Circle one)
No risk at all

Somewhat at risk

Good deal at risk

Extremely at risk

Please answer these statements by circling either YES OR NO.

23.

I worry about getting HIV.

YES

24.

I think that HIV is a serious
problem in my community.

YES

I have thought about how to
protect myself from HIV.

YES

25.

Nia-Appendix D: Pre-Intervention Assessment Survey
A-5

The statements below describe feelings or thoughts you may have about condoms.
For each question, please circle an answer to indicate whether you agree or disagree
with the statement.
26.

The use of condoms can make sex more exciting.

Disagree

Agree

27.

Condoms are uncomfortable.

Disagree

Agree

28.

1 find it embarrassing to be seen buying condoms.

Disagree

Agree

29.

Using condoms can be pleasurable.

Disagree

Agree

30.

Using condoms can show concern and caring.

Disagree

Agree

31.

Condoms ruin the "mood."

Disagree

Agree

32.

Condoms mess up foreplay.

Disagree

Agree

33.

I feel comfortable when I buy condoms.

Disagree

Agree

34.

Condoms don't always work.

Disagree

Agree

35.

Condoms are an effective method of
preventing sexual diseases.

Disagree

Agree

36.

I feel good about sex with a condom.

Disagree

Agree

37.

Most women would break up with me
if I said we had to use a condom.

Disagree

Agree

Disagree

Agree

38.

My friends would approve of me using a condom.

Nia-Appendix D: Pre-Intervention Assessment Survey
A-6

Now, vividly imagine a situation with a person where they want to have sex with you
without a condom. Imagine that you are very attracted to this person and want to
be with them, and they really want to have sex with you. Please circle the number
beside each statement below that best describes how confident you are that you can
do each.
Definitely
Not Confident
I

Somewhat
Confident
2

Definitely
Confident
3

39.

I will keep condoms nearby.

40.

I w i l l r e m i n d my s e l f t o u s e a
condom during sex.

I will bring up the need
to use a condom.

I will tell myself that sex with a condom is
as good as sex without a condom.
1

44.

I will not drink or use drugs before sex.

45.

I will refuse to have sex without
a condom, even if my partner
pressures me to have unsafe sex.

I will decide ahead of time what I will
and will not agree to do.
1

I will actively guide our actions to safe sex. 1

41.

42.
43.

46.
47.

I will use a condom.

Nia-Appendix D: Pre-Intervention Assessment Survey
A-7

Now please think carefully about risky situations like the one on the previous page.
Please circle the number beside each statement below that best describes how
certain you are that you can do each.
Definitely
Not Certain

Somewhat
Certain

Definitely
Certain

48.

I can know when a situation is risky.

49.

I can avoid being in a risky situation.

50.

I can use a condom.

51.

I can talk to my partner about using condoms.

Please circle your answer to the following questions.
52.

When you have sex, how often do you have a condom with you?
1
2
Every time Almost Every Time

53.

3
Sometimes

4
Almost Never

5
Never

When you have sex, how often do you use a condom?

1
Every Time

2
Almost Every Time

3
Sometimes

4
Almost Never

5
Never

54.
How likely do you think it is that from now on you will use a condom every time
you have sex?
1
Very Likely

2
Likely

3
Unlikely

Nia-Appendix D: Pre-Intervention Assessment Survey
A-8

4
Very Unlikely

Please circleyour answer to the following.
55.
Have you ever shared needles to
inject (shoot-up) drugs?
56.
57.

Have you had a sex partner who you
think used needles to shoot-up drugs?
Have you given someone money,
drugs, or other things to get sex?

58.

Have you ever had sex with another man?

59.

Have you been treated for a sexual disease (VD, STD)
such as Syphilis, Gonorrhea, Herpes, or Chlamydia?
If YES, how many times?

Nia-Appendix D: Pre-Intervention Assessment Survey
A-9

YES

Now please think carefully about the past 2 months and fill in the spaces with the
number of times you have had these types of sex or number of partners you have had.
If you do not remember the actual number, please estimate this to the best of your
ability.
In the past 2 months, I have...
60.

Had Vaginal sex without latex condoms (rubbers) __ (number of times) in
the past 2 months.

61.

Had Vaginal sex with use of latex condoms (rubbers) __ (number of times)
in the past 2 months.

62.

Had Anal (in the butt) sex without latex condoms (rubbers) __ (number of
times) in the past 2 months.

63.

Had Anal (in the butt) sex with use of latex condoms (rubbers) __ (number
of times) in the past 2 months.

64.

Gotten Oral sex (your partner performed oral sex on you) without a condom
_____ (number of times) in the past 2 months.

65.

Given Oral sex (you performed oral sex on your partner) without a condom or
latex barrier_______ (number of times) in the past 2 months.

66.

Gotten Oral sex (your partner performed oral sex on you) with a condom
_____ (number of times) in the past 2 months.

67.

Given Oral sex (you performed oral sex on your partner) with a condom or latex
barrier ______ (number of times) in the past 2 months.

68.

Drunk alcohol (beer, wine, etc.) before having sex __ (number of times) in
the past 2 months.

69.

Used other drugs (marijuana, cocaine, or others) __ (number of times)
before having sex in the past 2 months.

70.

H a d s e x w i t h _ _ _ _ (number of women) in past 2 months.

71.

H a d s e x w i t h _ (number of men) in past 2 months.

72.

Talked with my partner about using condoms ___ (number of times) in the
past 2 months.

73.

Refused to have sex because I did not have a condom __ (number of times)
in the past 2 months.

Nia-Appendix D: Pre-Intervention Assessment Survey
A-10

74.

Planned ahead of time to practice safer sex __ (number of times) in the past
2 months.

In the past 2 months, I have ...
75.

Drunk less or used drugs less before having sex to be safe __ (number of
times) in the past 2 months.

76.

Talked with a sex partner about getting tested for HIV __ (number of times)
in the past 2 months.

THANK. YOU FOR YOUR TIME. PLEASE RETURN THIS
QUESTIONNAIRE TO THE FACILITATOR.

Nia-Appendix D: Pre-Intervention Assessment Survey
A-11

Form Approved
OMB No. 0990Exp. Date __/__/20__

Participant ID Code:

Today's Date:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0990. The time
required to complete this information collection is estimated to average (25 minutes) per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E,
Washington D.C. 20201, Attention: PRA Reports Clearance Officer

A-1

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Please answer this question by circling the number below that best describes what you
think your risk is for getting HIV.

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Please answer these statements by circling either YES OR NO.

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The statements below describe feelings or thoughts you may have about condoms. For
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statement.

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A-2

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A-3

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THANK YOU FOR YOUR TIME.
PLEASE RETURN THIS QUESTIONNAIRE TO THE FACILITATOR.

A-4

Form Approved
OMB No. 0990Exp. Date __/__/20__

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0990. The time
required to complete this information collection is estimated to average (25 minutes) per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E,
Washington D.C. 20201, Attention: PRA Reports Clearance Officer

A-1

'RHVZDVKLQJGUXJHTXLSPHQWZLWKZDUPZDWHUNLOO+,9"

<(6

'RPRVWW\SHVRIELUWKFRQWURODOVRSURWHFWDJDLQVW+,9"

<(6

Please answer this question by circling the number below that best describes what you
think your risk is for getting HIV.

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+,9"

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Please answer these statements by circling either YES OR NO.
17.

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YES

19.

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YES

The statements below describe feelings or thoughts you may have about condoms. For
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statement.

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Agree

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Agree

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A-2

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Now, vividly imagine a situation with a person where they want to have VH[with you.
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really want to have sex with you. Please circle the number beside each statement below
that best describes how confident you are that you can do each.
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A-3

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A-4

Now please think carefully about the past 2 months and fill in the spaces on the next page.
In the past 2 months, I have had...

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UXEEHUV

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How many times in the past 2 months have you...

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A-5

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THANK YOU FOR YOUR TIME.
PLEASE RETURN THIS QUESTIONNAIRE TO THE FACILITATOR.

A-6

Form Approved
OMB No. 0990Exp. Date __/__/20__

Nia: Participant Satisfaction Survey
Participant ID Code:
I. What did you like most about the Nia group sessions?

2. How do you feel you benefited from participating in the Nia group?

3. Did you feel comfortable sharing your experiences with members of the group? Was
there anything that the facilitators could have done to help you be more comfortable?

4. How do you feel that tension or conflict within the group was handled by the
facilitators? Was there anything that the facilitators could have done differently to
handle conflict or tension?

5. What topics needed more time for discussion?

6. What topics would you have liked to have had in the sessions that were not covered?

THANK YOU FOR YOUR HELP!

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is
0990. The time required to complete this information collection is estimated to average (25 minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s)
or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA,
200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

A-1

Form Approved OMB No. 0990-0334
Exp.Date 03/31/2012

Prevention Education Pre-Test Questionnaire for College Women
INSTRUCTIONS: Check the box 5 next to your answer.
DATE: _____________________

ID#: _

INFORMATION ABOUT YOU
1. How old are you? _______ (Specify in
years)

____

4. What is your race and ethnicity?
F I do not wish to provide this
information.

2. What is your classification in college?
F Freshman
F Sophomore
F Junior
F Senior
F Other (Specify)______________

Ethnicity: (Select one)
F Hispanic or Latina
F Not Hispanic or Latina
Race: (Select all that apply)
F American Indian or Alaska
Native
F Asian
F Black or African American
F Native Hawaiian or Other
Pacific Islander
F White

3. How long have you been at this
institution? ______________ (Specify in
months or years)

What is your language of preference?
(Check all that apply)
F English
F Spanish
F Other (Specify)______________

GEARS Inc.

3/18/09

Confidential Proprietary Information

A-1

7. Where do you currently live?
F On campus dorm/student
housing
F At home with parents/relatives
F Off campus apartment with
roommates
F Off campus with partner
F Don’t have a stable living
arrangement
F Other (Specify)______________

6. What is your relationship status?
F Single
F Married
F Married but separated
F Common Law
F Common Law but separated
F Partnered
F Divorced
F Widowed
F Other (Specify)______________

8. Do you have access to health care?
F Yes
F No
F Don’t know
*************************************************************************************
KNOWLEDGE ABOUT HIV
For each statement, please circle “True” (T), “False” (F), or “I don’t know” (DK). If you do not know,
please do not guess; instead, please circle “DK”.
1. Coughing and sneezing DO NOT spread HIV.

2. A person can get HIV by sharing a glass of water
with someone who has HIV.

3. Pulling out the penis before a man
climaxes/cums keeps a woman from getting HIV
during sex.

4. A woman can get HIV if she has anal sex with a
man.

5. Showering, or washing one’s genitals/private
parts after sex keeps a person from getting HIV.

6. All pregnant women infected with HIV will have
babies born with HIV.

7. In general, people who have been infected with
HIV quickly show serious signs of being infected.

8. There is a vaccine that can stop adults from
getting HIV.

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9. People are likely to get HIV by deep kissing,
putting their tongue in their partner’s mouth, if
their partner has HIV.

10. A woman cannot get HIV if she has sex during her
period.

11. There is a female condom that can help decrease
a woman’s chance of getting HIV.

12. A natural skin condom works better against HIV
than does a latex condom.

13. A person will NOT get HIV if she or he is taking
antibiotics.

14. Having sex with more than one partner can
increase a person’s chance of being infected with
HIV.

15. Taking a test for HIV one week after having sex
will tell a person if she or he has HIV.

16. A person can get HIV by sitting in a hot tub or a
swimming pool with a person who has HIV.

17. A person can get HIV from unprotected oral sex.

18. Using Vaseline or baby oil with condoms lowers
the chance of getting HIV.

19. People can contract the HIV virus through
tattooing or body piercing if sterile instruments
are not used.

20. It is easier for a woman to get HIV than to give it.

21. A woman can give HIV to her baby or a sexual
partner through breast milk.

22. Taking an oral contraceptive or hormones
decreases your risk to get HIV.

23. Having unprotected sex with a partner is like
having sex with all of their current and previous
partners.

24. When I get a pap smear, I’m automatically tested
for STIs/STDs.

25. Ethnic minority women have higher rates of HIV
and STIs/STDs than white women.

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26. Your HIV risk increases if you or your sexual
partner injects drugs.

27. Douching decreases a woman’s risk for getting
HIV.

28. Using alcohol or party drugs increases the risk for
getting HIV by impairing your judgement.

******************************************************************************
YOUR EXPERIENCES
6. In the past 30 days, how many times did
Have you ever engaged in:
you give oral sex? ______ (Please give
(Select all that apply)
number)
F Oral Sex
7. In the past 30 days, how many times did
F Vaginal Sex
you give oral sex without a latex
F Anal sex
barrier? _______ (Please give number)
F I have never engaged in oral,
8. In the past 30 days, how many times did
vaginal or anal sex.
you receive oral sex? _______ (Please
How old were you when you first had:
give number)
F Oral sex? Age_____
9. In the past 30 days, how many times did
F Vaginal sex? Age_____
you receive oral sex without a latex
F Anal sex? Age_____
barrier? ________ (Please give number)
F I have never engaged in oral,
10. In the past 30 days, how many times did
vaginal or anal sex.
you have vaginal sex? ______ (Please
How would you describe yourself?
give number)
(Select all that apply)
11. In the past 30 days, how many times did
F Straight/Heterosexual
you have vaginal sex without a
F Gay/Lesbian/Homosexual
condom? _______ (Please give number)
F Bisexual
12. In the past 30 days, how many times did
F Transgendered
you have anal sex? _______ (Please
F Unsure
give number)
F Other (Specify)______________
13. In the past 30 days, how many times did
When you have sex, you have sex with:
you have anal sex without a condom?
(Select One)
________ (Please give number)
F Men
14. In the past 30 days, did you have sex
F Women
without a condom with someone who is
F Both
not your spouse or primary partner?
F Neither – I have never had oral,
F Yes
F No
vaginal, or anal sex.
Have you had sex in the past 30 days?
F Yes
F No

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22. In the past 30 days, have you ever felt
forced or intimidated into having sex
without a condom?
F Yes
F No
23. What is the age of your current or last
partner? _________
24. Have you ever been tested for a
sexually transmitted infection/disease
(STI/STD)? (Select one)
F Yes
F No
F Do not wish to answer
25. If yes, when were you last tested?
_______________ (mm/yy)
26. Have you ever been treated for a
sexually transmitted infection/disease
(STI/STD)? (Select one)
F Yes
F No
F Do not wish to answer
27. Have you ever been tested for HIV?
(Select one)
F Yes
F No
F Do not wish to answer
28. If yes, when were you last tested?
___________ (mm/yy)
29. Have you ever been told that you have
HIV? (Select one)
F Yes
F No
F Do not wish to answer
30. Have you had a pap smear in the last 12
months?
F Yes
F No
31. Have you ever spent time in a detention
center, jail or prison?
F Yes
F No

15. In the past 30 days, did you have sex
without a condom with someone who
shoots drugs with needles? (Select one)
F Yes
F No
F Don’t know
16. In the past 30 days, did you have sex
without a condom in exchange for
drugs?
F Yes
F No
17. In the past 30 days, did you have sex
without a condom because you feared
losing a financial benefit (gas, grocery,
rent, clothes, etc.)?
F Yes
F No
18. In the past 30 days, did you have sex
without a condom while you or your
partner were “high” on drugs or
alcohol? (Select one)
F Yes
F No
F Don’t know
19. In the past 30 days, how many different
sexual partners have you had?
________ (Please give number)
20. In the past 30 days, with how many
different people have you engaged with
in the following acts?
F Giving oral sex_______
F Receiving Oral sex______
F Vaginal sex_______
F Anal sex_________
21. In the past 30 days, have you ever had
sex without a condom because you
feared losing a partner?
F Yes
F No

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42. Are you worried about getting
HIV/AIDS?
F Not at all
F A little
F Somewhat
F A lot
43. Are you worried about getting a
sexually transmitted infection/disease
(STI/STD)?
F Yes
F No
44. Are you worried that you may already
have been exposed to HIV/AIDS?
F Yes
F No
45. Would you use a female condom if your
male sex partner didn’t want to use a
male condom?
F Yes
F No
46. Have you ever had unprotected sex
with a new partner because you were
upset with, just broke up with, or been
dumped by your current partner?
F Yes
F No
47. Have you ever had unprotected sex
with a new partner because you were
upset about school or your grades?
F Yes
F No
48. Have you ever dated someone who you
knew had HIV/AIDS?
F Yes
F No
49. Have you ever had unprotected oral,
anal, or vaginal sex with someone who
you knew was HIV positive?
F Yes
F No

32. Have any of your sexual partners been
in a detention center, jail or prison?
(Select one)
F Yes
F No
F I don’t know
33. Have you ever felt that alcohol or drugs
were a problem for you?
F Yes
F No
34. Are you currently in a monogamous
relationship?
F Yes
F No
35. Do you receive financial assistance from
your sexual partner(s)?
F Yes
F No
36. Are you currently using contraceptives
to keep from getting pregnant (i.e. birth
control pills, diaphragms, etc.)?
(Select one)
F Yes
F No
F Not currently sexually active
37. Are you currently trying to get
pregnant?
F Yes
F No
38. Do you have any children?
F Yes
F No
39. If yes, how many?
I have ____ children.
40. Have you ever been forced to have sex
when you didn’t want to?
F Yes
F No
41. Has your current partner ever physically
hurt you?
F Yes
F No

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52. I would feel comfortable discussing
condom use with a potential sexual
partner.
F Strongly disagree
F Disagree
F Not sure
F Agree
F Strongly agree
53. How comfortable did you feel
answering these questions honestly?
F Very uncomfortable
F Somewhat uncomfortable
F Somewhat comfortable
F Very comfortable

50. If I were to suggest using a condom to a
partner, I would feel afraid that he or
she would reject me.
F Strongly disagree
F Disagree
F Not sure
F Agree
F Strongly agree
51. If I were unsure of my partner’s feelings
about using condoms, I would not
suggest using one.
F Strongly disagree
F Disagree
F Not sure
F Agree
F Strongly agree

Page 7 of 7
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A-7

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0990. The time required to complete this information
collection is estimated to average (25 minutes) per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for
improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E,

BEFORE attending today’s session, how likely were you to engage in behaviors that may put
you at risk for HIV/AIDS?
Not at All
Likely
1

Somewhat
Likely

Moderately
Likely

Extremely
Likely

AFTER attending today’s session, how likely are you to engage in behaviors that may put you
at risk for HIV/AIDS?
Not at All
Likely
1

Somewhat
Likely

Moderately
Likely

Extremely
Likely

BEFORE attending today’s session, did you know where you could go to get a free HIV test?
No

Yes

AFTER attending today’s session, do you know where you could go to get a free HIV test?
No

Yes

Form Approved
OMB No. 0990Exp. Date __/__/20__

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0990. The time required to complete this information collection is
estimated to average (25 minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201,

A-1

Form Approved
OMB No. 0990Exp. Date __/__/20__

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0990. The time
required to complete this information collection is estimated to average (25 minutes) per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E,
Washington D.C. 20201, Attention: PRA Reports Clearance Officer

A -1

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0990. The time required to complete this information collection
is estimated to average (1 hour) per response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201,
Attention: PRA Reports Clearance Officer

14. How often do you use a condom during sex (e.g., anal, oral, and/or vaginal)?
All the time
Inconsistently
7
6
5
4
3

Never
1

THANK YOU!!!

IRB QUESTIONS AND ANSWERS
1. Type of document (survey, FG guide, key informant guide, consent form, etc.)
x

Sociodemographic Questionnaire

2. What is the purpose of it?
x

To gather quantitative data using from participants focusing on demographic information, sexual
behaviors, HIV testing behaviors, and relationships with others using forced-choice items and
Likert-type scales.

3. What is the target population(s)?
x

African American MSMs enrolled at HBCUs

4. What is the target number of individuals to take part in the survey/interview?
x

5. Is this form finalized or still a draft?
x

Yes, it is finalized.

File Type	application/pdf
File Title	Microsoft Word - MSI HIV OMB Supporting Statements AB _APPENDIX A ONLY 10 25 11_mr.doc
Author	robinsonm
File Modified	2012-02-14
File Created	2012-02-14