Form 2b 2012 Short Interview Questionnaire for Medical Monitorin
Medical Monitoring Project
Att_2b short interview v8 1 1
Patient Short interview
OMB: 0920-0740
Form Approved
OMB Number: 0920-0740
2012 Short Interview Questionnaire for
Medical Monitoring Project (MMP)
Do not use in field until May 2012
VERSION 8.1.1
Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC, Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0740). Do not send the completed form to this address.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
Atlanta, GA 30333
Table of Contents
HIV Testing and Care Experiences 10
HIV Treatment and Adherence 22
General notes for QDS programmers (additional programming notes are located throughout the questionnaire):
Use version 2.4 of QDS.
Every question requires a response to move forward in the application unless otherwise noted.
Use the following values: .D = 8, .R = 7, NA = 6.
Add a questionnaire type variable (one for the standard version and one for the short version).
For all “other-specify” variables in “check all that apply” questions, use the “other” variable name (which should end in “O”) and add an “S” on the end. If the variable name becomes too long, then drop the letter immediately preceding the consecutive letter at the end of the main part of the variable name. For example, if the “other” variable is named “KINDG_9O”(where KIND is the stem variable name and G denotes the lettered response option) the “specify” variable should be named “KING_9OS”
QDS programming notes are not included in the application; they are merely there to help with coding.
Interviewer instructions and inconsistency checks are notes for the interviewers, but may also include coding instructions.
Code book should have a brief description of the variable. This includes all calculated variables.
Calculate version number using variable name VERSION.
Calculate data collection cycle using variable name CYCYR. CYCYR = 2012.
For all date variables also create an automatic variable that is a copy of the date variable. For example, if the variable for date was called DATE, then the automatic variable would look like: a. variable name: TXFORM, b. type of date: String Expression, c. numeric calculation/string expression: DATE
Label module sections in the code book. Use the Table of Contents for guidance.
PDP start date is January 1, 2012.
PDP end date is April 30, 2012.
RTS-PDP start date is four months prior to date of interview (e.g., if interview date is April 30, 2012, then RTS PDP start date is January 1, 2012.
RTS-PDP end date is date of interview.
Calculate the time to conduct an interview from D1 to L6.
Calculate time to conduct each module.
Do not include the Facility Visits Log, Response cards, and calendars in the QDS program.
Distinguish between English and Spanish versions of the questionnaires (note this is different than the language variable used in the short questionnaire).
Add a calculated variable MODE to distinguish between HAPI and CAPI users.
2012 MMP Short Questionnaire
Preliminary Information (I)
Interviewer instructions: Enter Preliminary Information prior to interview.
I1. Participant ID [PARID]
Site ID [SITEID] ___ ___ ___ ___
Facility ID [FACILID] ___ ___ ___ ___
Respondent ID [INDID] ___ ___ ___ ___
QDS programming note:
Site ID, Facility ID, and Respondent ID all must be 4 digits with leading 0s. [PARID] is a 12 digit calculated variable based on [SITEID] + [FACILID] + [INDID]
I2. Interviewer ID: ___ ___ ___
[INTID]
QDS programming note:
Range 0-999
I2a. Handheld and computer device ID: ___ ___ ___
[DEVICEID]
QDS programming note:
Range 0-999
I3. Interview setting: [CHECK ONLY ONE.] [INTSE_12]
Outpatient health facility 1
Inpatient health facility 2
Prison or jail facility 3
Community-based organization 4
Private home 5
Public venue (i.e., coffee shop, library) 6
Health department 7
Telephone 8
Other (Specify_____________) 77 [INT_12OS]
I4. Interview date: __ __/ __ __ / __ __ __ __
[IDATE] (M M / D D / Y Y Y Y)
QDS programming notes for I4: Automatically calculate in QDS.
I5. Interview language: [LANGUAG]
English 1
Spanish 2
Other (Specify_______________________) 3 [LANGUAOS]
I6. Are you conducting a telephone interview or face-to-face interview? [TI_F2F]
Telephone interview 1
Face-to-face interview 2
I7. Was the patient selected through real time sampling (RTS) and interviewed between [INSERT PDP START DATE] and [INSERT PDP END DATE]? [RTS_SAMP]
No 0
Yes 1
I8. Was the interview originally administered on paper? [MODEADM]
No 0
Yes 1
Demographics
SAY: “I’d like to thank you for taking part in this interview. Remember that all the information you give me will be confidential and your name won’t be recorded in the survey responses. The answers to some questions may seem obvious to you, but I need to ask you all of the questions.”
Interviewer instructions: If I6 [TI_F2F] is “telephone interview,” then go to Say box below; otherwise skip to D1.
SAY: “You have chosen to complete the interview over the telephone. Before we begin, I would like to remind you that there is a set of response cards that I will ask you to refer to throughout the course of the interview. These response cards will be needed for some of the questions you will be asked during the interview. The set of cards contains a calendar and text to help guide you through the response options for some of the questions. Each card is labeled. Please keep this set of response cards nearby so you can use them when needed. I will let you know which questions require response cards and the label that corresponds to the card that is needed.”
Skip to Q2
No
0
Skip to Say box before Q2
Yes 1
Refused
to answer
7
Skip to Q2
Don’t
know
8
Q1a. What month and year did you participate in the MMP interview? [PARTIC]
__ __ / __ __ __ __
( M M Y Y Y Y ) [Month: 77 = Refused to answer, 88= Don’t know;
Year: 7777 = Refused to answer, 8888 = Don’t know]
Inconsistency check: Q1a (date participated in MMP) cannot be earlier than January 2005 or later than I4 (interview date). If Q1a is “Refused to answer” or “Don’t know,” skip to Q2.
QDS programming note for Q1a: This requires a full response for month and year. A full response could be “don’t know” or “refused” to some or all of the components of this date variable.
Q1b. In what city were you interviewed?
_____________________________________ (City) [CITY_9]
[7 = Refused, 8 = Don’t know]
Q1c. In what state were you interviewed?
_____________________________________ (State) [STATE_9]
[7 = Refused, 8 = Don’t know]
Interview instructions: If Q1a (date participated in MMP) is during the 2012 data collection cycle, “Refused to answer,” or “Don’t know,” go to Say box before Q2; otherwise, skip to Q2.
QDS programming note for Interviewer instructions after Q1c: parameters for the 2012 data collection cycle are May 1, 2012 to I4 (interview date).
SAY: “We are only interviewing people who haven’t already been interviewed during 2012 (2013). Thank you very much for your time.” [DISCONTINUE INTERVIEW AND SKIP TO INTERVIEW COMPLETION.]
QDS programming note for Say box after Q1c: use 2012 if the year in I4 (date of interview) is 2012. Use 2013 if the year in I4 (date of interview) is 2013.
Q2. What is your date of birth? [DOB]
__ __/ __ __ / __ __ __ __
(M M / D D / Y Y Y Y )
[Month: 77 = Refused to answer, 88= Don’t know;
Day: 77 = Refused to answer, 88= Don’t know;
Year: 7777 = Refused to answer, 8888 = Don’t know]
Inconsistency check: Q2 (date of birth) cannot be earlier than January 1, 1900 or later than I4 (interview date).
Interviewer instructions: If the respondent was less than 18 on January 1, 2012 (PDP start date), go to Say box before Q3; otherwise, skip to Q3. If Q2 is “Refused to answer” or “Don’t know,” go to Say box before Q3.
QDS programming note for Q2: This requires a full response for month, day, and year.
SAY: “We are only interviewing people who were 18 years or older on January 1, 2012. Thank you very much for your time.” [DISCONTINUE INTERVIEW AND SKIP TO INTERVIEW COMPLETION.]
Q3. What is the highest level of education you completed? [DON’T READ CHOICES. CHECK ONLY ONE.] [EDUC]
Never attended school 1
Grades 1 through 8 2
Grades 9 through 11 3
Grade 12 or GED 4
Some college, associate’s degree, or technical degree 5
Bachelor’s degree 6
Any post-graduate studies 7
Refused to answer 77
Don’t know 88
Q4. Do you consider yourself to be Hispanic or Latino? [HISPAN_9]
No 0
Yes 1
Refused to answer 7
Don’t know 8
Q5. Which racial group or groups do you consider yourself to be in? You may choose more than one option. [READ CHOICES. CHECK ALL THAT APPLY.] [RACE_9]
American Indian or Alaska Native 1 [RACE9_A]
Asian 2 [RACE9_B]
Black or African American 3 [RACE9_C]
Native Hawaiian or Other Pacific Islander 4 [RACE9_D]
White 5 [RACE9_E]
Refused to answer 77
Don’t know 88
Q6. In what country or territory were you born? [DON’T READ CHOICES. CHECK ONLY ONE. [CO_BORN]
Skip to Q7
United States 1
Puerto Rico 2
Mexico 3
Cuba 4
Other (Specify____________________________) 5 [OTCTRY]
Skip to Q7
Refused to answer 7
Don’t know 8
Interviewer instructions: If Q6a (years living in the U.S.) is < 1 year, enter “0.”
Q6a. How many years have you been living in the United States? [US_YRS]
___ ___ ___ years [Years: 777 = Refused to answer, 888 = Don’t know]
Inconsistency check: Q6a (years living in the U.S.) must be ≤ the respondent’s age at the date of the interview. Range 0-776.
Q7. What was your sex at birth? [READ CHOICES EXCEPT “Intersex/ambiguous”. CHECK ONLY ONE.] [BIRTGEN]
Male 1
Female 2
Intersex/ambiguous 3
Refused to answer 7
Don’t know 8
Q8. Do you consider yourself to be male, female, or transgender? [READ CHOICES. CHECK ONLY ONE.] [GENDER]
Male 1
Female 2
Transgender 3
Refused to answer 7
Don’t know 8
SAY: “Now I am going to ask you about the past 12 months. We will use the calendar to refer to the past 12 months. That is from last year (DATE WITH PREVIOUS YEAR) to now (INTERVIEW DATE).”
QDS programming note for Say box before Q9: The QDS program should enter the appropriate dates. EXAMPLE: If IDATE is 11/11/2012 then the program should read “That is from last year, 11/11/2011 to now 11/11/2012.”
Q9. During the past 12 months, have you had any kind of health insurance or health coverage? This includes Medicaid and Medicare. [HTHINS_9]
Skip to Say box before Q10
No
0
Yes 1
Skip to Say box before Q10
Refused to answer 7
Don’t know 8
Q9a. During the past 12 months, was there a time that you didn’t have any health insurance or health coverage? [INS12_9]
No 0
Yes 1
Refused to answer 7
Don’t know 8
Access to Care
HIV Testing and Care Experiences
SAY: “Now I’m going to ask you some questions about getting tested for HIV.”
Q10. What month and year did you first test positive for HIV? Tell me when you got your result, not when you got your test. [POS1S_9]
__ __/ __ __ __ __
(M M / Y Y Y Y ) [Month: 77 = Refused to answer, 88= Don’t know;
Year: 7777 = Refused to answer, 8888 = Don’t know]
Inconsistency check: Q10 (date first tested positive for HIV) cannot be earlier than Q2 (respondent’s date of birth). If Q10 is earlier than March 1985 or later than April 30, 2012, the PDP end date, confirm response.
QDS programming note for Inconsistency check after Q10: If Q10 is earlier than 03/1985, display note to the interviewer: “The date entered is earlier than 03/1985 (date of first FDA-approved HIV test). Confirm date of HIV test.” Program should move forward regardless of date. Allow a “??” response for month response. If Q10 is later than April 30, 2012, display note to interviewers: “The date entered is after 04/30/2012 (PDP end date). Go back to previous question to confirm date of HIV test.” The program will then go to the Say box 1 before Q11.
Interviewer instructions: If Q10 (date first tested positive for HIV) is after April 30, 2012, go to the Say box 1 before Q11. If Q10 is “Refused to answer,” “Don’t know,” or the month is unknown (??), skip to Q13. If Q10 (date first tested positive for HIV) is 5 years or less than April 30, 2012, go to Q11; otherwise skip to Q13.
SAY 1: “We are only interviewing people who tested positive for HIV before April 30, 2012. Thank you very much for your time.” [DISCONTINUE INTERVIEW AND SKIP TO INTERVIEW COMPLETION.]
SAY 2: “Now I’m going to ask you about HIV medical care. When I say ‘HIV medical care,’ I mean physical exams, prescriptions for HIV medicines, or lab tests such as HIV viral load and CD4 testing.”
Q11. Since testing positive for HIV, what month and year did you first visit a doctor, nurse, or other health care worker for HIV medical care? [CARE_9]
__ __/ __ __ __ __
(M M / Y Y Y Y ) [Month: 77 = Refused to answer, 88= Don’t know;
Year: 7777 = Refused to answer, 8888 = Don’t know]
Inconsistency check: Confirm response if Q11 (date first went to provider for HIV care) is earlier than the Q10 (date first tested positive for HIV) or later than April 30, 2012, the PDP end date.
QDS programming note for Inconsistency check after Q11: If Q11 is earlier than Q10, display note to interviewer: “The date entered is earlier than the date first tested positive for HIV care. Go back to previous question to confirm the date.” Allow the program to advance. If Q11is later than 04/30/2012 display a note to the interviewer: “The date entered is later than April 30, 2012 (PDP end date). Go back to previous question and confirm response.” Allow the program to advance. Allow a “??” for month response.
Interviewer instructions: If Q11 (date first went to provider for HIV care) is > 3 months after Q10 (date first tested positive for HIV), go to Q12; otherwise, skip to Q13. If Q11 is “Refused to answer,” “Don’t know,” or an unknown month (??), skip to Q13.
Q12. What was the main reason you didn’t go to a doctor, nurse, or other health care worker for HIV medical care within 3 months of testing positive for HIV? [DON’T READ CHOICES. CHECK ONLY ONE.] [MRNOCA_9]
Felt good 1
Initial CD4 count and viral load were good 2
Didn’t believe test result 3
Didn’t want to think about being HIV positive 4
Didn’t have enough money or health insurance 5
Had other responsibilities such as child care or work 6
Experienced homelessness 7
Was drinking or using drugs 8
Felt sick 9
Forgot to go 10
Missed appointment(s) 11
Moved or out of town 12
Unable to get transportation 13
Facility is inconvenient (location, facility hours, wait-time) 14
Didn’t know where to go 15
Couldn’t find the right HIV health care provider 16
Unable to get earlier appointment 17
Unaware of recommendation to enter care within 3 months 18
Other (Specify:________________________________) 19 [MRNO_9OS]
Refused to answer 77
Don’t know 88
Q13. When was your most recent visit to a doctor, nurse, or other health care worker for HIV medical care? Please tell me the month and year. [LASCA_9]
__ __/ __ __ __ __
(M M / Y Y Y Y ) [Month: 77 = Refused to answer, 88= Don’t know;
Year: 7777 = Refused to answer, 8888 = Don’t know]
Inconsistency check: Q13 (date of most recent visit to a provider for HIV care) cannot be earlier than Q11 (date first visit to a provider for HIV care) or later than I4 (interview date).
QDS programming note for Q13: Allow a “??” for month response.
Interviewer instructions: If Q13 (date of most recent visit to a provider for HIV care) is > 6 months prior to I4 (interview date), go to Q13a; otherwise, skip to Say box before Q14. If Q13 is “Refused to answer,” “Don’t know,” or an unknown month (??), skip to Say box before Q14.
SAY: “For this next question we will use the calendar to refer to the past 6 months.”
Q13a. What was the main reason you didn’t visit a doctor, nurse, or other health care worker for HIV medical care during the past 6 months? [DON’T READ CHOICES. CHECK ONLY ONE.] [MRNOC_10]
Felt good 1
CD4 count and viral load were good 2
Didn’t believe test result 3
Didn’t want to think about being HIV positive 4
Didn’t have enough money or health insurance 5
Had other responsibilities such as child care or work 6
Experienced homelessness 7
Was drinking or using drugs 8
Felt sick 9
Forgot to go 10
Missed appointment(s) 11
Moved or out of town 12
Unable to get transportation 13
Facility is inconvenient (location, facility hours, wait-time) 14
Didn’t know where to go 15
Couldn’t find the right HIV health care provider 16
Unable to get earlier appointment 17
Other (Specify:________________________________) 18 [MRN_10OS]
Refused to answer 77
Don’t know 88
Sources of Care
SAY: “Now I’m going to ask you some questions about the places where you get HIV medical care. If you don’t remember everything, that’s okay. Tell me what you remember.”
Q14. During the past 12 months, was there one usual place, like a doctor’s office or clinic, where you went for most of your HIV medical care? [PLCARE_9]
Skip to Q14b
Yes
1
Skip to Q15
Don’t know 8
Q14a. What was the main reason you didn’t have a usual place to get HIV medical care during the past 12 months? [READ CHOICES. CHECK ONLY ONE.] [UC_RS_10]
Couldn’t afford a usual source of HIV care 1
Didn’t know where to find a usual source of HIV care 2
Couldn’t get regular appointments anywhere 3
It wasn’t available in the area 4
Didn’t think it was necessary 5
Thought it was necessary, but never tried to get a usual
source of care 6
Other (Specify___________________________________) 7 [UC_R10OS]
Refused to answer 77
Don’t know 88
Interviewer instructions: Skip to Q15.
Q14b. What is the name of this place where you went for most of your HIV medical care
during the past 12 months?
QDS programming note: response for this question is not recorded in QDS.
Interviewer instructions: Go to paper Facility Visits Log and enter facility information for this place. Write USL in the Facility Type Code column. After entering this information, continue with the next question.
If I7 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I7 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
Q14c. Did you get any sort of care at [USE FACILITY NAME] between [INSERT START DATE]
and [INSERT END DATE]? [CAREPER1]
Skip to Q15
Yes 1
Skip to Q15
Don’t know 8
Interviewer instructions: If I7 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I7 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
Q14d. Between [INSERT START DATE] and [INSERT END DATE], how many times had you been to [USE FACILTY NAME] for any sort of care? [TIMECAR]
___ ___ ___ [777 = Refused to answer, 888 = Don’t know]
Inconsistency check: The number of times the respondent visited a particular facility must be ≥ 1 and ≤ 121.
Q15. During the past 12 months, had you been to any other doctor’s office or clinic for your HIV medical care? [OHEPRO_9]
Skip to Q16
Yes 1
Skip to Q16 
Don’t know 8
Q15a. What is the name of this place where you got HIV medical care?
QDS programming note: response for this question is not recorded in QDS.
Interviewer instructions: Go to paper Facility Visits Log and enter facility information for this place. Write OTH in the Facility Type Code column. After entering this information, continue with the next question.
If I7 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I7 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
Q15b. Did you get any sort of care at [USE FACILITY NAME] between [INSERT START DATE] and [INSERT END DATE]? [CAR1_1_9]
Skip to Q16
No 0
Yes 1
Skip to Q16
Don’t know 8
Interviewer instructions: If I7 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I7 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
Q15c. Between [INSERT START DATE] and [INSERT END DATE], how many times had you been to [USE FACILITY NAME] for any sort of care? [TIM1_1_9]
___ ___ ___ [777 = Refused to answer, 888 = Don’t know]
Inconsistency check: The number of times the respondent visited a particular facility must be ≥ 1 and ≤ 121.
Q16. During the past 12 months, how many times did you go to an emergency room or urgent care center for HIV medical care? [ERU_VI_9]
___ ___ [77 = Refused to answer, 88 = Don’t know]
Inconsistency check: Q16 (number of times respondent visited the emergency room or urgent care center for HIV care) must be ≤ 76.
Q17. During the past 12 months, how many times were you admitted to a hospital because of an HIV-related illness? (Please don’t include visits that were made only to the emergency room.) [HOSP]
___ ___ [77 = Refused to answer, 88 = Don’t know]
Inconsistency check: Q17 (number of times respondent was admitted to a hospital for an HIV-related illness) must be ≤ 76.
Q18. During the past 12 months, were you enrolled in an inpatient mental health facility? [ADMENH_9]
No 0
Yes 1
Refused to answer 7
Don’t know 8
Q19. During the past 12 months, were you enrolled in an inpatient drug or alcohol treatment facility? [ADDRAL_9]
No 0
Yes 1
Refused to answer 7
Don’t know 8
Met and Unmet Needs
SAY: “For the next set of questions we will use Response Card C. I’m going to ask about services you used or needed during the past 12 months. I'll ask you about each of the services that are listed on Response Card C. First I'll ask whether you received the service; then I'll ask whether you needed this service. If you weren't able to get this service, I’ll ask you the main reason you weren't able to get it. These questions might sound similar, but I need to ask you all of the questions”
QDS programming note for Say box before met and unmet need questions: The QDS program should enter the appropriate dates. EXAMPLE: If IDATE is 11/11/2012 then the program should read “That is from last year, 11/11/2009 to now 11/11/2012.”
Interviewer instructions: If response to Q20a is “No,” “Refused to answer,” or “Don’t know,” go to Q20b; otherwise, skip to Q21a. If response to Q20b is “Yes,” go to Q20c; otherwise, skip to Q21a. Follow the same pattern for Q20–Q37.
Interviewer instructions: For Q20c–Q37c: [DON’T READ CHOICES. CHECK ONLY ONE.]
|
|
During the past 12 months, did you get: |
IF “NO” IN Q20a–Q37a, ASK: During the past 12 months, have you needed: |
IF “YES” IN Q20b–Q37b, ASK: What was the main reason you haven’t been able to get this service during the past 12 months? |
|
|
CODE: No = 0, Yes = 1, Refused to answer = 7, Don’t know = 8 |
CODE: No = 0, Yes = 1, Refused to answer = 7, Don’t know = 8 |
CODE: SEE CODE LIST BELOW FOR RESPONSES. [DON’T READ CHOICES. CHECK ONLY ONE]
|
Q20. |
HIV case management services
|
a. [______] [HIVC12_9]
|
b. [______] [HIVCMS_9]
|
[HIVCRS_9] Other (Specify:________) [HIVC_9OS] |
Q21. |
Counseling about how to prevent the spread of HIV
|
a. [______] [HIVE12_9]
|
b. [______] [HIVEDU_9]
|
[HIVERS_9] Other (Specify:________) [HIVE_9OS] |
Interviewer instructions: If applicable, use the state program name for ADAP when asking Q22 (medicine through ADAP). |
||||
Q22. |
Medicine through the AIDS Drug Assistance Program (ADAP)
|
a. [______] [GET_ADAP]
|
b. [______] [NED_ADAP]
|
[RS_ADAP] Other (Specify:________) [RS_A_9OS] |
Q23. |
Professional help remembering to take your HIV medicines on time or correctly
|
a. [______] [ASS12_9]
|
b. [______] [ASS_9]
|
[ASSRS_9] Other (Specify:________) [ASSR_9OS] |
Q24. |
HIV peer group support
|
a. [______] [GET_GRP]
|
b. [______] [NED_GRP]
|
[RS_GRP] Other (Specify:________) [RS_G_9OS] |
Q25.
|
Dental care
|
a. [______] [DENS12_9] |
b. [______] [DENSER_9] |
[DENSRS_9] Other (Specify:________) [DENS_9OS] |
Q26. |
Mental health services
|
a. [______] [MENC12_9] |
b. [______] [MENCON_9] |
[MENCRS_9] Other (Specify:________) [MENC_9OS] |
Q27. |
Drug or alcohol counseling or treatment
|
a. [______] [GET_SUBU]
|
b. [______] [NED_SUBU]
|
[RS_SUBU] Other (Specify:________) [RS_U_9OS] |
Q28. |
Public benefits including Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)
|
a. [______] [GET_SSDI]
|
b. [______] [NED_SSDI]
|
[RS_SSDI] Other (Specify:________) [RS_S_9OS] |
Q29. |
Domestic violence services
|
a. [______] [GET_DOMS] |
b. [______] [NED_DOMS] |
[RS_DOMS] Other (Specify:________) [RS_D_9OS] |
Q30. |
Shelter or housing services
|
a. [______] [SHLT12_9] |
b. [______] [SHLTER_9] |
[SHLTRS_9] Other (Specify:________) [SHLT_9OS] |
Q31. |
Meal or food services
|
a. [______] [MLSF12_9]
|
b. [______] [MLSFOD_9] |
[MLSFRS_9] Other (Specify:________) [MLSF_9OS] |
Q32. |
Home health services
|
a. [______] [HHSA12_9] |
b. [______] [HHSASS_9] |
[HHSARS_9] Other (Specify:________) [HHSA_9OS] |
Q33. |
Transportation assistance
|
a. [______] [TRAS12_9] |
b. [______] [TRASAS_9] |
[TRASRS_9] Other (Specify:________) [TRAS _9OS] |
Q34. |
Childcare services
|
a. [______] [CHLD12_9] |
b. [______] [CHLDCR_9] |
[CHLDRS_9] Other (Specify:________) [CHLD_9OS] |
Q35. |
Interpreter services
|
a. [______] [GET_INTS] |
b. [______] [NED_INTS] |
[RS_INTS] Other (Specify:________) [RS_I_9OS] |
Q36. |
Nutritional services |
a. [______] [GET_NUTR] |
b. [______] [NED_NUTR] |
[RS_NUTR Other (Specify:________) [RS_N10OS] |
Q37. |
Other HIV-related services (Specify:____________)
|
a. [______] [OTS12_12] If “Yes,” then ask: Other 1 (Specify:________) [OTSP_121] Other 2 (Specify:________) [OTSP_122]
|
b. [______] [OTSER_12] If “Yes,” then ask: Other 1 (Specify:________) [OTSE_121] Other 2 (Specify:________) [OTSE_122]
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Other 1 ca. [______] [OTSR1_12] Other 1 (Specify:________) [O12_12OS] Other 2 cb. [______] [OTSR2_12] Other 2 (Specify:________) [O22_12OS]
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Code list for Q20c–Q37c
1 Didn’t know where to go or whom to call
2 In process of getting the service
3 Waiting list is too long
4 Service isn’t available
5 Not eligible or denied services
6 Transportation problems
7 Service hours are inconvenient
8 Service costs too much/lack of insurance
9 Language barrier
10 Too sick to get service
11 Psychological barrier
12 Other (Specify:____________________)
77 Refused to answer
88 Don’t know
HIV Treatment and Adherence
SAY: “Now I’m going to ask some questions about medicines that you are taking for your HIV. These medicines are called antiretrovirals, also known as ART, HAART, or the AIDS cocktail.”
Q38. Have you ever taken any antiretroviral medicines for your HIV? [ANTIRE_9]
No… 0
Skip to Q39
Skip to Interview completion
Don’t know….......... 8
Q38a. What is the main reason you have never taken any antiretroviral medicines? [DON’T READ CHOICES. CHECK ONLY ONE.] [NANTRE_9]
Doctor advised to delay treatment 1
Participant believed he/she didn’t need medications because
felt healthy or believed HIV laboratory results were good 2
Due to side effects of medication 3
Felt depressed or overwhelmed 4
Didn’t want to think about being HIV positive 5
Worried about ability to adhere 6
Drinking or using drugs 7
Money or insurance issues 8
Homeless 9
Taking alternative or complementary medicines 10
Other (Specify:______________________________) 11 [NANT_9OS]
Refused to answer 77
Don’t know 88
Interviewer instructions: Skip to Interview completion.
Q39. Are you currently taking any antiretroviral medicines for your HIV? [CURME_9]
No………………….…………………..…… 0
Skip to Q40a
Skip to Q40a
Don’t know….......... 8
Q39a. What is the main reason you aren’t currently taking any antiretroviral medicines? [DON’T READ CHOICES. CHECK ONLY ONE.] [NMANT8_9]
Doctor advised to delay or stop treatment 1
Participant believed he/she didn’t need medications because
felt healthy or believed HIV laboratory results were good 2
Due to side effects of medications 3
Felt depressed or overwhelmed 4
Didn’t want to think about being HIV positive 5
Worried about ability to adhere 6
Drinking or using drugs 7
Money or insurance issues 8
Homeless 9
Taking alternative or complementary medicines 10
Other (Specify:______________________________) 11 [NMA8_9OS]
Refused to answer 77
Don’t know 88
Skip to Interview completion
No………………….…………………..……
0
Yes………………………………………..……
1
Skip to Interview completion
Don’t know….......... 8
Q40a. During the past 12 months, what were the ways your antiretroviral medicines were paid for? [DON’T READ CHOICES. CHECK ALL THAT APPLY.] [PREM_12]
Private health insurance 1 [PREM_12A]
Medicaid 2 [PREM_12B]
Medicare 3 [PREM_12C]
AIDS Drug Assistance Program (ADAP) 4 [PREM_12D]
An AIDS service organization provided medicines 5 [PREM_12E]
Got medicines at a public clinic 6 [PREM_12F]
7
Clinical trial or drug study provided medicines 7 [PREM_12G]
Paid for medicines out of pocket 8 [PREM_12H]
Other 1 (Specify: _____________________________) 9 [PREO_12I] [PRE121OS]
Other 2 (Specify: _____________________________) 10 [PREJ_12O] [PRE122OS]
Refused to answer 77
Don’t know 88
Time questionnaire ended: ___ ___:___ ___ □ AM □ PM [ENDSHORT]
Hour Minute
Interview Completion (E)
End of Interview
SAY: “Thank you again for taking part in this interview. Please remember that all the information you have given me will be kept confidential.”
Interviewer instructions:
Offer assistance with information and resources, according to local protocol.
Don’t pay the respondent if the respondent already participated in an MMP interview during the 2012 data collection cycle OR the respondent is less than 18 years old.
Pay the respondent if the respondent’s first HIV positive test was after the PDP, OR the interview was partially or fully completed.
Payment Verification
Interviewer instructions: if I6 is “telephone interview,” go to E1; otherwise skip to E2.
E1. Have arrangements for payment been made? [ARRANGE]
No 0
Yes 1
Interviewer instructions: Skip to E4.
E2. Payment made: [PAYMENT]
No 0
Yes
1 Skip to E3
E2a. Why was payment not made? [PAYNMAD]
Skip to E4
Other (Specify:_____________________________) 2
[OPAY]
E3. Receipt signed (or initialed): [RECEIPT]
No 0
Yes
1 Skip to E4
E3a. Why was receipt not signed? [RECNS]
Participant refused to sign 1
Other (Specify:_____________________________) 2
Data Validity
E4. How confident are you of the validity of the respondent’s answers? [CONF]
Confident 1
Some doubts 2
Not confident at all 3
E5. Record any additional comments, including disruptions that might have taken place during the interview, reason the interview might have been stopped, or why the respondent’s answers may not have been reliable. [ADDCOM1]
QDS programming note for E4: Include a NA response option if Interviewers do not have any additional comments.
Facility Visits Log – Medical Monitoring Project 2012
Record information on facilities as indicated in the questionnaire. Only obtain contact information (street address/city/state) for facilities with which you are not familiar or those outside of your MMP project area’s jurisdiction. Interviewers should not write in the shaded row or column. After the interview is completed, this information should be entered into the DCC Tracking System.
Box A Interview Date: ___ ___/___ ___/ ___ ___ ___ ___
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Box B
___ ___ ___ ___ ___ ___ ___ ___ ____ ___ ___ ___ Site ID Facility ID Respondent ID |
Box C Interviewer ID: ___ ___ ___ |
Facility Type Code1 (from question) |
What was the name of this facility? |
What is the MMP 8-digit facility ID number? Data manager use only |
What was the name of the health care provider you usually saw there? |
About how many times did you go to this facility during the past 12 months? |
What was the street address of this facility? (complete as needed) |
What city and state was this facility in? (complete as needed) |
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City |
State |
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SAMP Data manager use only |
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Facility Type Codes:
USL = usual HIV care INC = care while incarcerated OTH = other HIV care OBGYN = OB or GYN care MED = general medical care HO = inpatient hospital
SAMP = facility where patient was sampled
Response Card C
HIV case management services
Counseling about how to prevent the spread of HIV
Medicine through the AIDS Drug Assistance Program (ADAP)
Professional help remembering to take your HIV medicines on time or correctly
HIV peer group support
Dental care
Mental health services
Drug or alcohol counseling or treatment
Public benefits including Supplemental Security Income (SSI) or Social Security
Disability Insurance (SSDI)
Domestic violence services
Shelter or housing services
Meal or food services
Home health services
Transportation assistance
Childcare services
Nutritional Services
Interpreter services
Other HIV-related services
2011 Calendar
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
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Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
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Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
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Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
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Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 |
2012 Calendar
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
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Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
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Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
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Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
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Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
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Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 |
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | OMB Number: 0920-0740 |
| Author | chx5 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |
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