Form Approved:
OMB No. 0920-0913
Expiration Date: 01/31/2015
Evaluating Locally-Developed HIV Prevention Interventions for African-American MSM in Los Angeles
Attachment 3d
Baseline Questionnaire
Public reporting burden of this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)
Form Approved:
OMB No. 0920-0913
Expiration Date: 01/31/2015
MyLife MyStyle
Baseline Questionnaire
Interview Date: ________________
Study ID: ________________
Instructions: Thank you for taking the time to answer questions for our study. Remember, all your answers will be kept private and your name will not be attached to any of the answers you provide today. It is important to be as honest as possible when answering these questions. Please remember that you can decide not to answer a specific question if you do not want to.
If you would like help understanding a question, please talk to the project staff member who can help you.
____________________________________________________________________________________
A. Demographics
A1. How old are you? Enter the number of years. ___ ___
A2. In the past 12 months, have you been homeless at any time? By homeless, I mean you were living on the street, in a shelter, a Single Room Occupancy hotel (SRO), temporarily staying with friends or relatives, or living in a car.
0 No
1 Yes
7 Refused to answer
9 Don’t know
In the past 3 months, have you been homeless at any time? By homeless, I mean you were living on the street, in a shelter, a Single Room Occupancy hotel (SRO), temporarily staying with friends or relatives, or living in a car.
1 Yes
0 No
7 Don't Know
8 Refuse to Answer
A3. Are you currently homeless?
0 No
1 Yes
7 Refused to answer
9 Don’t know
A4. Do you think of yourself as..... (Choose one)
1 Heterosexual or "Straight"
2 Homosexual or Gay
3 Bisexual
4 Other
7 Refuse to Answer
A5. Do you identify with any of
the following terms? (Check all that apply)
1 Queer
2 Same gender loving
3 In the life
4 On the 'down low'
5 None
6 Other: _______
7 Refuse to Answer
A6. Are you currently married or living with a partner (boyfriend, girlfriend)?
0 No [SKIP TO A8]
1 Yes
7 Refuse to Answer
A7. Is this person male, female, or transgender? (Choose one)
0 Male
1 Female
2 Transgender
7 Refuse to Answer
A8. What is the highest level of education you completed? (CHOOSE ONE)
0 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 Other: __________________
77 REFUSE TO ANSWER
A9. What best describes your employment status? (Choose one) Are you:
1 Employed full-time
2 Employed part-time
3 A full-time student
4 Disabled for work
5 Unemployed
6 Other
77 Refused to answer
99 Don't know
A10. Thinking about the past 12 months, how much was your total yearly income, before taxes were taken out? (Choose one)
1 Less than $5,000
2 $5,000 - $9,999
3 $10,000 - $19,999
4 $20,000 - $29,999
5 $30,000 - $39,999
6 $40,000 or more
7 Refuse to Answer
A11. How many people other than yourself does your income support?
___ ___
77 Refuse to Answer
A12. How many children do you have? ___ ___
A13. During the past 3 months, how often did you run out of money for your basic necessities like rent or food?
1 Never
2 Once
3 Twice
4 Three times or more
7 Refuse to answer
A14. Some people experience difficulty when looking for employment. Which of the following challenges have you faced when looking for a job? [Mark all that apply to your past experience.]
1 I haven’t had any challenges finding a job.
2 I don’t have the appropriate skills/training.
3 I don’t have the appropriate educational background.
4 I don’t have enough previous work experience.
5 I think employers have discriminated against me because of my race/ethnicity.
6 I think employers have discriminated against me because of my sexual orientation.
7 I don’t think I interview well.
8 I have a history of incarceration.
9 Other…..please specify__________________________________________
A15. What kind of health insurance or coverage do you currently have?
[Check all that apply.]
1 Medicaid (MediCal)
2 Medicare
3 Veteran's Administration
4 Ryan White
5 Private Insurance or HMO (e.g., Blue Cross or Kaiser)
6 No insurance
7 Self-pay
8 Other health insurance
77 Refuse to Answer
99 Don’t Know
The next few questions are about any experiences you may have had with the jail or prison system. Please answer as honestly as you can. Your answers will be kept private.
A16. Have you ever been arrested and taken to jail or prison? (Choose one)
0 Never
1 Once [ASK A16a]
2 Twice [ASK A16a]
3 Three times or more [ASKA16a]
7 Refuse to Answer
A16a. Have you been arrested and taken to jail or prison in the past 12 months?
0 No
1 Yes
7 Refuse to Answer
9 Don’t Know
A17. Have you ever been convicted of a felony?
0 No
1 Yes
7 Refuse to Answer
9 Don’t Know
A18. While you were in jail or prison, did you ever have unprotected anal sex with another inmate?
0 No
1 Yes
7 Refuse to Answer
9 Don’t Know
B. Integrated Race and Sexuality
The next several questions are about race and sexuality.
B1. Black homosexual and bisexual men contribute to black communities.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
77 Refuse to Answer
B2. Both my race and my sexuality are important to who I am as a man.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
77 Refuse to Answer
B3. I can’t imagine a loving relationship between two Black men.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
77 Refuse to Answer
B4. I believe Black men can be in loving committed relationships with each other.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
77 Refuse to Answer
B5. Black men who have sex with men do nothing to improve the quality of Black communities.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
77 Refuse to Answer
B6. Black homosexual and bisexual men can play an important role in Black families.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
77 Refuse to Answer
B7. A Black man who has sex with men can still be a strong man.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
77 Refuse to Answer
B8. It is more important that people see me as a man than as a Black person.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
77 Refuse to Answer
B9. It is more important that people see me as a man than as a homosexual/bisexual man.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
77 Refuse to Answer
B10. I am comfortable being open as a Black homosexual/bisexual man.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
77 Refuse to Answer
B11. Black homosexual and bisexual men only make it more difficult for Black people in general.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
77 Refuse to Answer
Sexual Behaviors
Next, are some questions about having sex. Please remember your answers will be kept private.
For these questions, "having sex" means oral, vaginal, or anal sex. Oral sex means mouth on the vagina, penis or anus (butt); vaginal sex means penis in the vagina; and anal sex means penis in the anus (butt). Note that some questions may not apply to your situation.
1. How old were you when you first had oral or anal sex with a male?
__ __
97 Refuse to Answer
98 Not Applicable
2. How old were you when you first had oral, vaginal or anal sex with a female?
__ __
97 Refuse to Answer
98 Not Applicable
3. In the past 3 months, that is since _____, with how many different men have you had oral or anal sex?
__ __ __
777 Refuse to Answer
888 Not Applicable
4. In the past 3 months, that is since _____, with how many different women have you had oral, vaginal, or anal sex?
__ __ __
777 Refuse to Answer
888 Not Applicable
5. In the past 3 months, that is since _____, with how many transgender persons have you had oral, vaginal, or anal sex?
__ __ __
777 Refuse to Answer
888 Not Applicable
The next questions are specifically about people you have had either anal or vaginal intercourse with in the past three months—between _____ and _______. These sex partners should not include anyone you ONLY had oral sex with.
6. With how many people have you had anal or vaginal intercourse in the past three months (since _____)?
__ __ __
Now we are going to ask you questions specifically about these partners or if you have had more than five partners in the past 3 months, please answer questions about the five you had sex with most often. First, please type in the initials, a nickname, or another easy way to refer to each partner in the past three months to help you in answering the questions.
________ ________ ________ _________ __________
What is partner X's gender? (Choose one)
1 Male
2 Female
3 Male to female transgender (transwoman) 4 Female to male transgender (transman)
7 Refuse to Answer
8 Not Applicable
9 Don't Know
How old is partner X?
__ __
97 Refuse to Answer
98 Not Applicable
99 Don't Know [ASK 2a]
2a. Was this partner….
1 About the same age as you (within five years)
2 Five or more years older than you
3 Five or more years younger than you
3. What type of partner is partner X? (Choose one)
1 Exchange Partner (Sex for money or goods) [Ask 3a]
2 Anonymous Partner (One time partner)
3 Casual Partner (Sex without commitment) [Ask 3b]
4 Main Partner (Primary sexual partner) [Ask 3b]
3a. Did you give partner X money or goods for sex OR did partner X give you money or goods for sex?
1 I gave this partner money or goods for sex
2 This partner gave me money or goods for sex
3b. When was the first time you had anal (or vaginal) sex with partner X?
1 Within the past 3 months
2 Between 3 and 12 months ago
3 Over 12 months ago
4. How would you describe partner X's race/ethnicity?
01 American Indian or Alaskan Native
02 Asian or Pacific Islander
03 Black, not of Hispanic origin
04 Hispanic
05 White, not of Hispanic origin
07 Other (specify)
77 Refuse to Answer
88 Not Applicable
99 Don't Know
5. Did you and partner X discuss each other’s HIV status before you had intercourse the first time?
0 No
1 Yes
7 Refuse to Answer
6. To the best of your knowledge, what is partner X’s HIV status?
0 Negative
1 Positive
2 Unknown/don’t know (GO TO Q8)
7. How do you know that partner X’s HIV status is ___? (Check all that apply)
1 I could tell by the way he looked
2 One of his friends told me what his status was
3 I could tell his status by some of the things that he told me
4 I checked out his medicine cabinet to look for HIV medications
5 He told me directly without me asking
6 I asked him directly and he told me
7 Other: Specify________________
8. Did you and partner X discuss each other’s STI status (sexually transmitted infections other than HIV ) before you had intercourse the first time?
0 No
1 Yes
7 Refuse to Answer
9. Where did you first meet partner X?
1 gay bar, cafe, nightclub or restaurant
2 sex club, bathhouse, adult novelty store or bookstore
3 public places including street, park, shopping mall, grocery store, library, public transportation
4 church, political function
5 work or school
6 gym / health club/ athletic activity
7 Internet (hook up, dating or social networking site)
8 newspaper ads
9 private party or social club
10 through friends
11 non-gay bar, nightclub
12 at In The Meantime program or event
13 social organizations / volunteer service activities
14 vacation / business
trip
15 some other way [Specify]:_____________
77 Refuse to Answer
88 Not Applicable
99 Don’t know
10. How many times did you have insertive anal intercourse (you put your penis in his butt)
with partner X in past 3 months (between _____ and _______)?
__ __
97 Refuse to Answer
98 Not Applicable
99 Don’t Know
11. Of the __ times you had insertive anal sex, how many times was a condom NOT used?
__ __
97 Refuse to Answer
98 Not Applicable
99 Don’t Know
12. Of the __ times you had insertive anal sex without a condom, how many times were you high or drunk? __ __
97 Refuse to Answer
98 Not Applicable
99 Don’t Know
13. How many times did you have receptive anal intercourse (he put his penis in your butt)
with partner X in past 3 months (between _____ and _______)?
__ __
97 Refuse to Answer
98 Not Applicable
99 Don’t Know
14. Of the __ times you had receptive anal sex, how many times was a condom NOT used?
__ __
97 Refuse to Answer
98 Not Applicable
99 Don’t Know
15. Of the __ times you had receptive anal sex without a condom, how many times were you high or drunk? __ __
97 Refuse to Answer
98 Not Applicable
99 Don’t Know
16. In the past 3 months, how many times did you NOT have anal sex because you or partner X did not have a condom?
___ times
17. In the past 3 months, as far as you know, has partner X had sex with other people?
0 No
1 Yes, with other men
2 Yes, with women
3 Yes, with both men and women
4 Yes, but I don’t know who they had sex with
5 Don’t know
REPEAT FOR UP TO FOUR PARTNERS
[FOR PARTICIPANTS WITH MAIN MALE PARTNERS]
18. In the past 3 months, that is since _____, how many times did you ask partner X to get tested for sexually transmitted infections (STIsnot including HIV)?
__ __
97 Refuse to Answer
98 Not Applicable
99 Don’t Know
19. In the past 3 months, that is since _____, how many times did you ask partner X if he was being faithful to you?
__ __
97 Refuse to Answer
98 Not Applicable
99 Don’t Know
19a. Did he tell you that he had been unfaithful to you in the past 3 months?
0 No
1 Yes
7 Refuse to Answer
9 Don't Know
20. Who usually has more say about whether you use condoms?
1 Your partner
2 Both of you equally
3 You
21. Who usually has more say about what types of sexual acts you do?
1 Your partner
2 Both of you equally
3 You
22. In general, who do you think has more power in your relationship?
1 Your partner
2 Both of you equally
3 You
[FOR FEMALE PARTNERS, Q21-Q26]
23. How many times did you have vaginal intercourse with partner X in the past 3 months (between _____ and _______)?
__ __
97 Refuse to Answer
98 Not Applicable
99 Don’t Know
24. Of the __ times you had vaginal sex, how many times did you NOT use a condom?
__ __
97 Refuse to Answer
98 Not Applicable
99 Don’t Know
25. Of the __ times you had vaginal sex without a condom, how many times were you high or drunk?
__ __
97 Refuse to Answer
98 Not Applicable
99 Don’t Know
26. How many times did you have anal intercourse (your penis in her butt) with partner X in past 3 months (between _____ and _______)?
__ __
97 Refuse to Answer
98 Not Applicable
99 Don’t Know
27. Of the __ times you had anal sex, how many times did you NOT use a condom?
__ __
97 Refuse to Answer
98 Not Applicable
99 Don’t Know
28. Of the __ times you had anal sex without a condom, how many times were you high or drunk?
__ __
97 Refuse to Answer
98 Not Applicable
99 Don’t Know
29. In the past 3 months, how many times did you NOT have vaginal or anal sex because you or partner X did not have a condom?
___ times
[FOR ALL RESPONDENTS]
30. In the past three months, did you have anal sex with any male sex partners because they gave you drugs, money, a place to stay, or other things you needed? (Choose one)
0 No
1 Yes, only with one man
2 Yes, with more than one man
7 Refuse to Answer
31. Before having sex with a man for the first time, how often do you discuss both of your HIV statuses? (Choose one)
1 All the time
2 More than half the time
3 About half the time
4 Less than half the time
5 None of the time
7 Refuse to Answer
32. Before having sex with a man for the first time, how often do you discuss being tested for sexually transmitted infections (STIs, like gonorrhea, Chlamydia but not including HIV)? (Choose one)
1 All the time
2 More than half the time
3 About half the time
4 Less than half the time
5 None of the time
7 Refuse to Answer
33. Before having sex with a man for the first time, how often do you discuss having safer sex (like mutual masturbation/oral sex instead of anal sex)? (Choose one)
1 All the time
2 More than half the time
3 About half the time
4 Less than half the time
5 None of the time
7 Refuse to Answer
34. In the past 3 months, how many times have you been in a situation where your partner wanted to have anal or vaginal sex without a condom?
__ __ [if 0, skip to 35]
97 Refuse to Answer
98 Not Applicable
99 Don’t Know
34a. Of those ___ times, how many times did you have anal or vaginal sex without a condom?
__ __
97 Refuse to Answer
98 Not Applicable
99 Don’t Know
35. How often do you use enemas (insert a fluid into the anus to clean it out), in preparation for anal sex?
1 Always
2 Often
3 Sometimes
4 Rarely
5 Never
36. How often do you expect your partner to use enemas (insert a fluid into the anus to clean it out) in preparation for anal sex?
1 Always
2 Often
3 Sometimes
4 Rarely
5 Never
37. During the past 3 months, how emotionally satisfying was your sex life?
1 Not at all satisfying
2 Slightly satisfying
3 Moderately satisfying
4 Very satisfying
5 Extremely satisfying
38. During the past 3 months, how physically pleasurable was your sex life?
1 Not at all pleasurable
2 Slightly pleasurable
3 Moderately pleasurable
4 Very pleasurable
5 Extremely pleasurable
Sexual Abuse History
The next section is about incidents that may have happened to you when you were a child, that is, before the age of 18. These questions may bring up difficult memories, but please try to answer them as honestly as you can.
1. Before the age of 18, did a relative, family member, friend, or stranger ever feel you up, fondle your body including your butt or genitals, or rub their genitals against your body in a sexual way when you didn’t want them to?
0 No
1 Yes
7 Refuse to Answer
9 Don't Know
2. Before the age of 18, did anyone force you to perform oral sex on them or to receive oral sex from them?
0 No
1 Yes
7 Refuse to Answer
9 Don't Know
3. Before 18, did anyone try to force you to have intercourse against your will? (This includes instances where someone attempted to put their penis, finger or other object in your butt).
0 No
1 Yes
7 Refuse to Answer
9 Don't Know
4. Before 18, did anyone have intercourse with you against your will? (This includes instances where someone put their penis, finger or other object in your butt).
0 No
1 Yes
7 Refuse to Answer
9 Don't Know
[If yes to any of Q1-4, ask 5 and 6]
5. How old were you the first time that any of these experiences happened?
__ __
97 Refuse to Answer
98 Not Applicable
99 Don't Know
6. Do you think these early, unwanted sexual experiences caused you to be gay or homosexual?
0 No
1 Yes
7 Refuse to Answer
9 Don't Know
D. Internalized Homophobia
The next several questions are about attractions to men.
In the past 3 months, I have tried to stop being attracted to men.
1 Strongly disagree
2 Disagree somewhat
3 Neither agree nor disagree
4 Agree somewhat
5 Strongly agree
8 Refuse to Answer
If someone offered me the chance to be completely heterosexual (straight), I would accept it.
1 Strongly disagree
2 Disagree somewhat
3 Neither agree nor disagree
4 Agree somewhat
5 Strongly agree
8 Refuse to Answer
I wish I were not sexually involved with men.
1 Strongly disagree
2 Disagree somewhat
3 Neither agree nor disagree
4 Agree somewhat
5 Strongly agree
8 Refuse to Answer
I would change my sexual preferences if I could.
1 Strongly disagree
2 Disagree somewhat
3 Neither agree nor disagree
4 Agree somewhat
5 Strongly agree
8 Refuse to Answer
In the past 3 months, I have tried to become more sexually attracted to women.
1 Strongly disagree
2 Disagree somewhat
3 Neither agree nor disagree
4 Agree somewhat
5 Strongly agree
8 Refuse to Answer
I try to avoid personal or social involvement with gay or homosexual men.
1 Strongly disagree
2 Disagree somewhat
3 Neither agree nor disagree
4 Agree somewhat
5 Strongly agree
8 Refuse to Answer
I try to avoid personal or social involvement with men who are bisexual or sexually active with both men and women.
1 Strongly disagree
2 Disagree somewhat
3 Neither agree nor disagree
4 Agree somewhat
5 Strongly agree
8 Refuse to Answer
I don't like being gay/homosexual.
1 Strongly disagree
2 Disagree somewhat
3 Neither agree nor disagree
4 Agree somewhat
5 Strongly agree
8 Refuse to Answer
I wish that I could develop more sexual desire towards women.
1 Strongly disagree
2 Disagree somewhat
3 Neither agree nor disagree
4 Agree somewhat
5 Strongly agree
8 Refuse to Answer
I am uncomfortable being attracted to men.
1 Strongly disagree
2 Disagree somewhat
3 Neither agree nor disagree
4 Agree somewhat
5 Strongly agree
8 Refuse to Answer
I value my sexuality as it is.
1 Strongly disagree
2 Disagree somewhat
3 Neither agree nor disagree
4 Agree somewhat
5 Strongly agree
8 Refuse to Answer
12. I try to avoid contact with overly effeminate men.
1 Strongly disagree
2 Disagree somewhat
3 Neither agree nor disagree
4 Agree somewhat
5 Strongly agree
8 Refuse to Answer
E. Gender Role Conflict
Please answer the next set of questions about how you might show affection for others.
Verbally expressing my love or caring for another man is difficult for me.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
8 Refuse to Answer
Affection with other men makes me tense.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
8 Refuse to Answer
Expressing my emotions to other men is risky.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
8 Refuse to Answer
Men who touch other men make me uncomfortable.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
8 Refuse to Answer
Hugging other men is difficult for me.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
8 Refuse to Answer
I am sometimes hesitant to show my affection to men because of how others might perceive me.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
8 Refuse to Answer
Being very personal with other men makes me feel uncomfortable.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
8 Refuse to Answer
Men who are overly friendly make me wonder about their sexual preference.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
8 Refuse to Answer
9. I never want to look or seem weak.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
8 Refuse to Answer
10. Men should never show their feminine side.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
8 Refuse to Answer
11. I do not want to seem effeminate, girlish, or womanly.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
8 Refuse to Answer
12. It is important for men to look tough.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
77 Refuse to Answer
13. Men must seem strong to be respected.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
77 Refuse to Answer
Social Support for Safer Sex/Risk Reduction
The next set of questions are about people you know including friends and family members.
1. Who have you told that you have sex with men? (Check all that apply)
1 My mother or the woman who raised me
2 My father or the man who raised me
3 My brother(s)
4 My sister(s)
5 My minister or priest
6 Straight friends
7 Gay friends
8 Therapist
9 Health care provider
10 My teacher/counselor
11 Other: ____________
77 Refuse to Answer
2. How important is it for you that people who are close to you know that you have sex with men? (Choose one)
1 Very important
2 Somewhat important
3 A little important
4 Not at all important
7 Refuse to Answer
3. How close do you feel to your family? On a scale of 1 to 5 with 1 = “Not at all close” and 5 =“Extremely close” ____
How much do you agree or disagree with the following statements about your family?
4. I have family members who:
remind me to stay safe sexually.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
will try to advise me if they think I’m in an unhealthy relationship.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
encourage me to know the truth about my HIV/STI status.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
remind me to protect myself from HIV/STIs.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
encourage me to always use condoms.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
would express concern if I tell them my boyfriend is having sex with other people.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
are supportive of me being monogamous in my relationships with men.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
h. I can talk to if I find out I have an STI.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
i.. I can talk to if I have unprotected sex.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
j. are willing to talk to me about the intimate details of my sex life.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
5. What kind of influence does your family have on your ability to practice safer sex?
1 Very negative
2 Negative
3 Neither negative nor positive
4 Positive
5 Very positive
How much do you agree or disagree with the following statements about your friends?
6. I have friends who:
a. remind me to stay safe sexually.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
b. will try to advise me if they think I’m in an unhealthy relationship.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
c. encourage me to know/find out my HIV status.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
d. remind me to protect myself from HIV/STIs.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
e. encourage me to always use condoms.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
f. would express concern if I tell them my boyfriend is having sex with other people.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
g. are supportive of me being monogamous in my relationships with men.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
h. I can talk to if I find out I have an STI.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
i. I can talk to if I have unprotected sex.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
j. are willing to talk to me about the intimate details of my sex life.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
7. What kind of influence do your friends have on your ability to practice safer sex?
1 Very negative
2 Negative
3 Neither negative nor positive
4 Positive
5 Very positive
Homophobia and Sexual Identity/Sexual Relationships
The next set of questions are about sexual identity and sexual or love relationships.
1. Homophobia makes it harder for me to find a sexual or love relationship.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
2. I have strong Black gay male role models who help me feel more comfortable being open about my sexual orientation.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
3. I would feel comfortable bringing a male partner home for a family gathering and introducing him as my boyfriend.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
4. I avoid family gatherings because of the pressure of not having a girlfriend.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
5. I avoid family gatherings because family members suspect I’m gay.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
6. I sometimes change the way I look after leaving my home to go out to a gay club or venue (so that no one will suspect I’m going to a gay venue).
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
7. I change the way I act and talk when I am around straight black men.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
8. I put up with anti-gay jokes when I am in a setting like a barbershop.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
9. When I talk about dating with my family (or others who don’t know I date men), I refer to my male partners as she or them and not “him.”
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
Knowledge of HIV Risk for Self and Community
These next few questions are about the risk of HIV among young Black men. “ MSM” in these questions refers to men who have sex with men.
Most new HIV infections among Black MSM occur among Black MSM younger than 30.
1 True
2 False
9 Don't Know
Compared with other MSM, Black MSM have the lowest rates of HIV/AIDS.
1 True
2 False
9 Don't Know
About 1 in 3 Black MSM in Los Angeles may be HIV infected.
1 True
2 False
9 Don't Know
At least half of HIV-infected Black MSM do not know they have the virus.
1 True
2 False
9 Don't Know
Black MSM are more likely to know they have HIV compared with White MSM.
1 True
2 False
9 Don't Know
Men who have an STI (sexually transmitted infection like syphilis, gonorrhea) are more likely to get HIV or transmit HIV during sex.
1 True
2 False
9 Don't Know
The rate of HIV infection is higher for young Black MSM than for any other group.
1 True
2 False
9 Don't Know
8. Half of all HIV-positive people in the U.S. are African American or Black.
1 True
2 False
9 Don't Know
HIV/AIDS Knowledge and Risk Reduction
Please answer the following questions about HIV and AIDS.
If a man pulls out before cumming, rubbers or condoms don't need to be used to protect against HIV/AIDS.
1 True
2 False
9 Don't Know
Most people who have HIV/AIDS look sick.
1 True
2 False
9 Don't Know
Vaseline and other oils should not be used to lubricate rubbers or condoms.
1 True
2 False
9 Don't Know
Rubbers or condoms made of latex products protect against the HIV/AIDS virus.
1 True
2 False
9 Don't Know
Cleaning injection needles with water is enough to kill the HIV/AIDS virus.
1 True
2 False
9 Don't Know
If someone has HIV, they will have a sunken face and a large belly.
1 True
2 False
9 Don't Know
Rubbers or condoms made of lambskin protects against the HIV/AIDS virus.
1 True
2 False
9 Don't Know
Many people who have HIV/AIDS feel and look healthy.
1 True
2 False
9 Don't Know
Hand lotion is a good lubricant to use with a condom or rubber.
1 True
2 False
9 Don't Know
It is almost impossible for a man to get HIV during sex with another man if he is the top (the insertive partner).
1 True
2 False
9 Don't Know
You have to have sex with someone more than once to get HIV/AIDS.
1 True
2 False
9 Don't Know
If the man you are having sex with agrees not to have sex with other people, you have no reason to use a condom or rubber.
1 True
2 False
9 Don't Know
You cannot get HIV by touching an infected person's sweat.
1 True
2 False
9 Don't Know
Some sexually transmitted diseases cause men to become sterile.
1 True
2 False
9 Don't Know
Having a sexually transmitted disease does not affect a person's risk of getting HIV.
1 True
2 False
9 Don't Know
16. If an HIV positive person has an undetectable viral load, they cannot transmit HIV through sex.
1 True
2 False
9 Don't Know
17. Because of the “window period”, it is possible to get an HIV-negative test result and still have HIV.
1 True
2 False
9 Don't Know
18. An HIV-positive person is most infectious (can spread HIV easily) in the first few weeks after getting infected.
1 True
2 False
9 Don't Know
HIV and STI Testing
How many times in your life have you been tested for HIV?
______times
In the past 2 years, that is, since [insert calculated month and year], how many times have you been tested for HIV?
______times
When did you have your most recent HIV test? (Please take your best guess at the month, if you do not remember the exact month)
___/___ MM/YY
What was the result of your last HIV test?
HIV negative
HIV positive
Did not get results
4. Indeterminate/inconclusive
5. When you got tested in _____/______ [insert date from Q3], did you get tested for any of the following reasons:
a. Because you thought you might have been exposed to HIV in the 3 to 6 months before the test?
No
Yes
7 Refused to Answer
8 Don’t know
b. Because you got tested on a regular basis and it was time for you to get tested again?
1 No
2 Yes
7 Refused to Answer
8 Don’t know
c. Because you had symptoms that made you think you should get tested?
1 No
2 Yes
7 Refused to Answer
8 Don’t know
d. Because you were just checking to make sure you were HIV negative?
1 No
2 Yes
7 Refused to Answer
8 Don’t know
e. Because your doctor or health care provider recommended you get tested?
1 No
2 Yes
7 Refused to Answer
8 Don’t know
f. Because you were required to get tested by either insurance, the military, a court order, or by some other agency?
1 No
2 Yes
7 Refused to Answer
8 Don’t know
g. Because there was some other reason you wanted to get tested?
1 No
2 Yes
7 Refused to Answer
8 Don’t know
h. (Specify other reason ___________________________)
1. Has a doctor, nurse, or other health care provider ever told you that you had any of the following sexually transmitted infections (STIs)? [READ CHOICES, CHECK NO OR YES FOR EACH ONE]
|
No |
Yes |
Don’t Know |
If yes, did you get treated? |
a. Syphilis |
………0 |
………………….1 |
………………….9 |
Y / N |
b. Gonorrhea (clap or drip) |
………0 |
………………….1 |
………………….9 |
Y / N |
c. Chlamydia |
………0 |
………………….1 |
………………….9 |
Y / N |
d. Genital herpes (HSV) |
………0 |
………………….1 |
………………….9 |
Y / N |
e. Genital warts (HPV) |
………0 |
………………….1 |
………………….9 |
Y / N |
f. Any Other STIs |
………0 |
………………….1 |
………………….9 |
Y / N |
f.1 If Yes: Specify |
_______________________ |
Y / N |
|
|
2. In the past 3 months has a doctor, nurse, or other health care provider told you that you had any of the following STIs? [READ CHOICES, CHECK NO OR YES FOR EACH ONE]
|
No |
Yes |
Don’t Know |
If yes, did you get treated? |
a. Syphilis |
………0 |
………………….1 |
………………….9 |
Y / N |
b. Gonorrhea (clap or drip) |
………0 |
………………….1 |
………………….9 |
Y / N |
c. Chlamydia |
………0 |
………………….1 |
………………….9 |
Y / N |
d. Genital herpes (HSV) |
………0 |
………………….1 |
………………….9 |
Y / N |
e. Genital warts (HPV) |
………0 |
………………….1 |
………………….9 |
Y / N |
f. Any Other STIs |
………0 |
………………….1 |
………………….9 |
Y / N |
f.1 If Yes: Specify |
_______________________ |
|
|
|
3. When was the last time you got tested for STIs (other than HIV)? (Please take your best guess at the month, if you do not remember the exact month)
___/___ MM/YY
4. Have you been vaccinated for hepatitis A or B?
0 No
1 Yes
7 Refuse to Answer
4a. If yes, was it for hepatitis A? ____
hepatitis B? ____
both A and B? ___
5. Have you been vaccinated for HPV (human papilloma virus, or genital warts)?
0 No
1 Yes
7 Refuse to Answer
6. How comfortable do you feel telling your doctor/health provider that you have anal sex?
1 Not comfortable at all
2 A little comfortable
3 Comfortable
4 Extremely comfortable
7. How comfortable do you feel telling your doctor/health provider that you are gay/bisexual?
1 Not comfortable at all
2 A little comfortable
3 Comfortable
4 Extremely comfortable
8. Has a doctor/health provider treated you differently after you shared your sexual identity?
1 Yes
2 No
7 Refuse to Answer
9 Does Not Apply
Self-efficacy for Condoms and Partner Communication
How
confident or sure are you that you could...
Put a male rubber or condom on a hard penis.
1 Not at all sure I can do
2 Somewhat unsure
3 Undecided
4 Somewhat sure
5 Completely sure I can do
Correctly unroll a rubber or condom down to the base of the penis on the first try.
1 Not at all sure I can do
2 Somewhat unsure
3 Undecided
4 Somewhat sure
5 Completely sure I can do
Squeeze the tip of the condom while rolling it down.
1 1 Not at all sure I can do
2 Somewhat unsure
3 Undecided
4 Somewhat sure
5 Completely sure I can do
Use water-based lubricant with a male condom.
1 Not at all sure I can do
2 Somewhat unsure
3 Undecided
4 Somewhat sure
5 Completely sure I can do
Now, please think about how well you would be able to do the following when using condoms.
I can talk to every new partner about the importance of using condoms.
1 Not at all sure I can do
2 Somewhat unsure
3 Undecided
4 Somewhat sure
5 Completely sure I can do
I can find another way to get off (such as mutual masturbation) when a condom isn't available.
1 Not at all sure I can do
2 Somewhat unsure
3 Undecided
4 Somewhat sure
5 Completely sure I can do
I can be the one to put the condom on my male partner even if I'm nervous.
1 Not at all sure I can do
2 Somewhat unsure
3 Undecided
4 Somewhat sure
5 Completely sure I can do
I can put a condom on myself or my partner so that it will not slip or break.
1 Not at all sure I can do
2 Somewhat unsure
3 Undecided
4 Somewhat sure
5 Completely sure I can do
I can get every potential partner to use a condom with me.
1 Not at all sure I can do
2 Somewhat unsure
3 Undecided
4 Somewhat sure
5 Completely sure I can do
I can use a condom with a new partner without breaking the mood.
1 Not at all sure I can do
2 Somewhat unsure
3 Undecided
4 Somewhat sure
5 Completely sure I can do
Even if we haven't used them in the past, I can make sex fun while using condoms with a partner.
1 Not at all sure I can do
2 Somewhat unsure
3 Undecided
4 Somewhat sure
5 Completely sure I can do
I can put a condom on myself or my partner and enjoy the experience.
1 Not at all sure I can do
2 Somewhat unsure
3 Undecided
4 Somewhat sure
5 Completely sure I can do
I can get a new partner to use a condom, even if I'm drunk or high.
1 Not at all sure I can do
2 Somewhat unsure
3 Undecided
4 Somewhat sure
5 Completely sure I can do
6 I don’t get drunk or high
I can get a partner who I haven't used condoms with before to use one, even if I'm drunk or high.
1 Not at all sure I can do
2 Somewhat unsure
3 Undecided
4 Somewhat sure
5 Completely sure I can do
6 I don’t get drunk or high
The next few questions are about discussing HIV status with your male sex partners.
I only tell a partner about my HIV status if we are going to have anal sex without a condom.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
I always talk to partners about my HIV status before having sex with them.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
I talk to all my partners about my HIV status even if we are just having oral sex.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
When a partner tells me he is HIV negative, I always ask when he was last tested.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
(For HIV+ or unknown) I sometimes lie about my HIV status to people I’m going to have sex with.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
Even if my partners tell me they are HIV negative, I tend not to believe them.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
I lose my desire to have sex if my partner tries to discuss HIV.
1 Strongly Disagree
2 Disagree Somewhat
3 Neither Agree nor Disagree
4 Agree Somewhat
5 Strongly Agree
Anal and Penile Health
These next few questions are about sexually transmitted infections or STIs (examples are gonorrhea, Chlamydia, syphilis, herpes, etc.).
STIs may increase a man’s HIV risk if he has openings/ulcers on his genitals.
1 True
2 False
9 Don't Know
An HIV-positive person who has an STI can more easily spread HIV to his or her sex partners.
1 True
2 False
9 Don't Know
Treating STIs helps to reduce the risk of getting HIV.
1 True
2 False
9 Don't Know
If condoms are used 100% of the time, a person cannot get an STI.
1 True
2 False
9 Don't Know
You can get hepatitis A from rimming (“eating ass”).
1 True
2 False
9 Don't Know
There is a vaccine for hepatitis A, B and C.
1 True
2 False
9 Don't Know
Condoms do not protect against Chlamydia.
1 True
2 False
9 Don't Know
Gonorrhea infections can be found in the anus, penis, and throat.
1 True
2 False
9 Don't Know
It is easy to detect an STI in the anal area.
1 True
2 False
9 Don't Know
Untreated syphilis can lead to brain damage and even death.
1 True
2 False
9 Don't Know
Using water-based lubricant for anal sex can help protect against anal tearing.
2 False
9 Don't Know
Pre Exposure Prophylaxis (PrEP)
(For HIV- and unknown men)
Scientists are currently doing studies to find new ways of preventing people from becoming infected with HIV. In these studies, people take a pill every day that contains the same medicine that is used to treat people who are infected with HIV. Scientists want to know if taking this medicine will prevent people exposed to HIV from becoming infected with it. They call this method pre-exposure prophylaxis or PrEP.
1. Before today, have you heard about pre-exposure prophylaxis or PrEP?
0 No
1 Yes
7 Refuse to Answer
2. A recent study showed that PrEP prevents HIV infection in 44% of the people who take it. Would you be willing to take PrEP pills every day to try to protect yourself from becoming infected with HIV?
0 No
1 Yes
7 Refuse to Answer
HIV Care and Treatment
(For HIV+ men)
This next set of questions has to do with care and treatment you may have received for your HIV.
1. Have you ever received any health care or treatment for HIV/AIDS?
1 Yes
2 No [If NO, go to Q8]
7 Refuse to Answer
2. When did you last go to your health care provider for HIV care?
___/___ [MM/YY]
3. Have you ever taken any HIV medications (antiretroviral medicines)?
1 Yes
2 No
7 Refuse to Answer
8 Don’t Know
If Q3 is equal to 2 or Q3 is equal to 7, then skip to Alcohol Questions.
4. Did your doctor take time to educate you about your HIV medications?
1 Yes
2 No
7 Refuse to Answer
8 Don’t Know
5. When did you last take any HIV medications (antiretroviral medicine)? (Choose one)
1 Within the past 3 months
2 3 - 5 months ago
3 6 - 12 months ago
4 More than a year ago
7 Refuse to Answer
If Q5 is not equal to 1, then skip to Alcohol Questions.
6. Are you currently taking any HIV medications (antiretroviral medicine)?
1 Yes
2 No
7 Refuse to Answer
7. Have you skipped taking any of your HIV medications (antiretroviral medicines) in the past 3 months?
1 Yes
2 No
7 Refuse to Answer
If Q2 is > 6 months, go to Q9 else go to Alcohol Questions.
8. What is the main reason you have never received any health care for your HIV infection? Choose only one reason.
Feel good. Don’t need to go
Don’t want to think about being HIV positive/Denial
Didn’t have money or insurance
Couldn’t find health care provider/Didn’t know where to go
Inconvenient (location/hours/time, etc.)
Forgot to go/Missed appointment
Too busy to go
Drinking or using drugs
Homeless
Appointment pending
I thought I would be treated poorly by the staff or medical provider because of my sexual orientation.
Other
77 Refuse to Answer
88 Don’t Know
9. What is the main reason you have not received HIV health care in the past 6 months? Choose only one reason.
1 Feel good. Don’t need to go
2 Don’t want to think about being HIV positive/Denial
3 Didn’t have money or insurance
4 Couldn’t find health care provider/Didn’t know where to go
5 Inconvenient (location/hours/time, etc.)
6 Forgot to go/Missed appointment
7 Too busy to go
8 Drinking or using drugs
9 Homeless
10 Appointment pending
11 I thought I would be treated poorly by the staff or medical provider because of my sexual orientation
11 Other
77 Refuse to Answer
88 Don’t Know
Alcohol/Drug Use
The next questions are about alcohol and drug use. Please remember your answers will be kept private. For these questions, "a drink of alcohol" means a 12 oz beer, a 5 oz glass of wine, or a 1.5 oz shot of liquor.
1. In the past 12 months, did you drink any alcohol such as beer, wine, malt liquor, or hard liquor?
0 No Skip to Q4
1 Yes
7 Refuse to answer
9 Don’t know
In the past 3 months, did you drink any alcohol such as beer, wine, malt liquor or hard liquor?
1 Yes
0 No Skip to 4
7 Don't Know
8 Refuse to Answer
2. In the past 30 days, on how many days did you drink any alcohol?
[77 = Refused, 99 = Don't know] __ __ If 0, 77, or 99 skip to Q4
3. In the past 30 days, how many times did you have 5 or more alcoholic drinks in one sitting?
[77 = Refused, 99 = Don't know] __ __
4. Other than alcohol, have you ever used drugs to get high?
0 No Skip to next section
1 Yes
7 Refuse to Answer
5. Have you used drugs in the past 3 months?
0 No Skip to next section
1 Yes
7 Refuse to Answer
6. In the past 3 months, have you used crystal methamphetamine, other amphetamines, crank, speed, ice, or Tina? 0 No
1 Yes
7 Refuse to Answer
7. In the past 3 months, have you used crack, powder cocaine or coke?
0 No
1 Yes
7 Refuse to Answer
8. In the past 3 months, have you used heroin?
0 No
1 Yes
7 Refuse to Answer
9. In the past 3 months, have you used club drugs such as ecstasy or X, G H B, ketamine, or Special K?
0 No
1 Yes
7 Refuse to Answer
10. In the past 3 months have you used amyl nitrate/poppers?
0 No
1 Yes
7 Refuse to Answer
11. In the past 3 months have you used marijuana?
0 No
1 Yes
7 Refuse to Answer
12. In the past 3 months have you used prescription drugs not prescribed to you?
0 No
1 Yes
7 Refuse to Answer
13. Have you ever in your life shot up or injected any drugs other than those prescribed for you? By shooting up, I mean anytime you might have used drugs with a needle, either by mainlining, skin popping, or muscling.
0 No
1 Yes
7 Refuse to Answer
8 Don’t know
9 Not applicable
14. In the past 3 months, did you tend to have more unprotected anal sex with men when you were under the influence of alcohol or drugs?
0 No
1 Yes, when using alcohol
2 Yes, when using drugs
3 Yes, with alcohol or drugs
7 Refuse to Answer
Internet and cell phone use
The next questions are about the Internet.
1. How do you usually access the Internet or go online? (Choose all that apply)
1 Cell phone
2 Computer at home
3 Computer at work
4 Computer in library or café
5 Other: Specify ______________
6 I don’t access the Internet
2. During the past 3 months, how often did you go online to connect with or find men for social and personal connections other than sex?
0 Never
1 Very rarely
2 Monthly
3 Weekly
4 Daily
3. During the past 3 months, how often did you go online to connect with or find male sex partners?
0 Never
1 Very rarely
2 Monthly
3 Weekly
4 Daily
4. During the past 3 months, how often did you use apps on a cell phone or mobile device to find people for sex? Examples of apps are Grindr and Facebook.
0 Never
1 Very rarely
2 Monthly
3 Weekly
4 Daily
If 4 is equal to Never, then skip.
4a. What apps did you use, please specify _______________.
5. How much do you agree with the following statement?
The Internet is one of the only places I can connect with other young Black men who have sex with men.
1 Strongly disagree
2 Disagree somewhat
3 Neither agree nor disagree
4 Agree somewhat
5 Strongly agree
8 Refuse to Answer
Psychological Distress (CES-D-10)
In this section, you are going to read a list of the ways you might have felt or behaved in the past week. Please check how often you have felt this way during the past week. The answers for each question in this section are the same.
When
you answer 'Less than one day' that would mean you felt that way
rarely or none of the time this past week,
'1 to 2 days' means
you have felt that way some or a little of the time this past
week,
'3 to 4 days' means you have felt that way occasionally
or a moderate amount of time this past week
'5
to 7 days' means you have felt that way most or all of the time this
past week.
1. During the past week, I was bothered by things that usually don't bother me. (CHOOSE ONE)
1 Less than one day
2 1 to 2 days
3 3 to 4 days
4 5 to 7 days
7 Refuse to Answer
2. During the past week, I had trouble keeping my mind on what I was doing. (CHOOSE ONE)
1 Less than one day
2 1 to 2 days
3 3 to 4 days
4 5 to 7 days
7 Refuse to Answer
3. During the past week, I felt depressed. (CHOOSE ONE)
1 Less than one day
2 1 to 2 days
3 3 to 4 days
4 5 to 7 days
7 Refuse to Answer
4. During the past week, I felt that everything I did was an effort. (CHOOSE ONE)
1 Less than one day
2 1 to 2 days
3 3 to 4 days
4 5 to 7 days
7 Refuse to Answer
5. During the past week, I felt hopeful about the future. (CHOOSE ONE)
1 Less than one day
2 1 to 2 days
3 3 to 4 days
4 5 to 7 days
7 Refuse to Answer
6. During the past week, I felt fearful. (CHOOSE ONE)
1 Less than one day
2 1 to 2 days
3 3 to 4 days
4 5 to 7 days
7 Refuse to Answer
7. During the past week, my sleep was restless. (CHOOSE ONE)
1 Less than one day
2 1 to 2 days
3 3 to 4 days
4 5 to 7 days
7 Refuse to Answer
8. During the past week, I was happy. (CHOOSE ONE)
1 Less than one day
2 1 to 2 days
3 3 to 4 days
4 5 to 7 days
7 Refuse to Answer
9. During the past week, I felt lonely. (CHOOSE ONE)
1 Less than one day
2 1 to 2 days
3 3 to 4 days
4 5 to 7 days
7 Refuse to Answer
10. During the past week, I could not "get going". (CHOOSE ONE)
1 Less than one day
2 1 to 2 days
3 3 to 4 days
4 5 to 7 days
7 Refuse to Answer
Thank you for answering those questions. We are now interested in knowing what things in your life cause you the most stress.
1. Please look at this list of things that can cause stress in a person’s life. What causes you stress on a regular basis? (Mark all that apply)
1 Finances, money
2 Health
3 Love relationships
4 Family
5 Job
6 Unemployment
7 Living situation
8 Threats of violence
9 Being found out as gay
10 Achieving life goals
11 Other, please specify _____________
Prevention Intervention Questions
1. Thinking about the past 3 months (between ___ and ____), what programs or events have you taken part in at In The Meantime Men’s Group? Mark all that apply:
Program |
Yes/No |
If yes, number of times attended in the past 3 months |
NIA group session |
|
|
Brothers Reaching Brothers (Tues night group) |
|
|
Kick Back group discussion (Thurs night group) |
|
|
Hang out at the Kick Back space |
|
|
Men’s Health Conference |
|
NA |
Umoja Retreat |
|
NA |
HIV testing on the In The Meantime testing van |
|
|
Any other special event. Please specify: ____________ |
|
|
I haven’t taken part in any programs or events sponsored by In The Meantime. |
|
NA |
2. Thinking about the past 3 months, what types of HIV prevention programs or interventions have you attended at another agency? Mark all that apply:
1 individual/one-on-one intervention
2 discussion or intervention with a group
3 HIV conference
4 HIV retreat
5 research study
Please specify: ______________
6 other program/intervention
Please specify: ______________
3. Thinking about all your male sex partners over the past three months, how many of them have participated in any MyLife MyStyle sessions?
_____ sex partners
4. How many of your friends have ever participated in any MyLife MyStyle sessions?
_____ friends
5. On a scale from 1 to 4, how honest were you in answering the questions in the survey today?
1 Not honest at all
2 A little bit honest
3 Somewhat honest
4 Very honest
| File Type | application/msword |
| File Title | MyLife MyStyle |
| Author | In The Meantime |
| Last Modified By | Bonds, Constance (CDC/OID/NCHHSTP) |
| File Modified | 2012-04-11 |
| File Created | 2012-04-11 |