Form Attachment 10 Attachment 10 6-Month Assessment

Critical Thinking and Cultural Affirmation: Evaluation of a Locally Developed HIV Prevention Intervention

6-mo Assessment_OMB Comments.7.4.12 revised_clean

6-month Assessment

OMB: 0920-0945

Document [docx]
Download: docx | pdf

CTCA Assessment Form Approved:

OMB No. 0920-

Expiration Date:




Critical Thinking and Cultural Affirmation (CTCA): Evaluation of a Locally Developed HIV Prevention Intervention




Attachment 10


6-month Follow-up Assessment







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)



CTCA ASSESSMENT

TABLE OF CONTENTS




Administrative:

Study Site: [LUCBMX]

Participant ID: [SUBJECT]

Staff ID: [STAFF]

Assessment Point: [ASSESS] [Baseline, 3-Month, 6-Month]

Date: [TODAY] –

The following may be considered as CORE if surveys are administered in QDS (or any program used for ACASI)

Version of Questionnaire: [VERSION] – Programmed as automatic variables in QDS

Starting Time: [STIME] – Programmed as automatic variable in QDS

Ending Time: [ETIME] – Programmed as automatic variable in QDS

Demographics

Module A: DEM -Demographics

DEM1. Date of Birth

In what month and year were you born? MM/YYYY

98 Refuse to Answer

DEM2. Gender

Are you…

01 Male – SKIP TO DEM 4

02 Transgender/Transsexual SKIP TO DEM 3

98 Refuse to Answer – SKIP TO DEM 4

DEM3. Transgender Identity

Are you…

01 Male to Female Transgender/Transsexual

02 Female to Male Transgender/Transsexual

98 Refused to Answer

DEM4. Hispanic or Latino

Do you consider yourself to be Hispanic or Latino?

01 Yes

02 No

98 Refuse to Answer


DEM5. Race

For this question you may select more than one option.

Do you consider yourself?

01 White

02 Black or African American -

03 Asian

04 American Indian or Alaska Native

05 Native Hawaiian or Pacific Islander

98 Refuse to Answer

DEM6. Education Level

What is the highest level of education you have completed? (Choose One)

01 < Grade 8

02 Grades 9 through 11

03 Grades 12 or GED

04 Some college, Associate’s Degree, or Technical Degree

05 Bachelor’s Degree

06 Any post graduate studies

98 Refuse to Answer

DEM7. Employment Status

What best describes your current employment status? (Choose One)

01 Employed full-time

02 Employed part-time

03 Unemployed but looking for work

04 Unemployed, am a student, not currently seeking employment

05 Unemployed, not a student, not currently seeking employment

98 Refuse to Answer

DEM8. Income Level

What was your household income last year from all sources before taxes? Household income refers to the total amount of money from all people living in the household. (Choose One)

01 less than $10,000

02 $10,000 -19,999

03 $20,000 –29,999

04 $30,000 –39,999

05 $40,000 –49,999

06 $50,000 –59,999

07 $60,000 –69,999

08 $70,000 –79,999 09 $80,000 or more

97 Don’t Know

98 Refuse to Answer

DEM9. Dependents

Including you, how many people depend on this income?

# of People

98 Refuse to Answer

DEM10. Children

How many children do you have? _____

98 Refuse to Answer

DEM11. Finance

During the past 12 months, how many times did you run out of money for your basic necessities like rent or food? (Choose one)

01 Never

02 Once

03 Twice

04 Three times or more

98 Refuse to Answer

DEM13. Incarceration

Have you ever spent at least one night in jail or prison? (Choose One)

01 Yes

02 No - SKIP TO DEM 15

98 Refuse to Answer

DEM14. Incarceration Time

Was this in the past 3 months?

01 Yes

02 No

98 Refuse to Answer

DEM15. Homelessness

In the past 3 months, were you homeless at any time? That is, you slept in a shelter for homeless people, on the streets, or another place not intended for sleeping.

01 Yes

00 No

98 Refuse to Answer

DEM16. Housing

In the past 3 months, have you experienced unstable housing at any time? That is, you lived with other persons or moved constantly because you did not have a place of your own.

01 Yes

02 No

98 Refuse to Answer

DEM17. Class Background

What do you consider your parents' class background?

01 Upper Middle Class

02 Middle Class

03 Working Class

04 Poor

98 Refuse to Answer


DEM18. Relationship Status

How do you define your CURRENT relationship status?

01 I am legally married OR My partner and I had a commitment ceremony

02 I have a partner or a lover

03 I have a boyfriend or a girlfriend

04 I have a boyfriend and a girlfriend

05 I am single

98 Refuse to Answer

DEM19. Population

Which type of area did you grow up in?

01 Large central city (population over 250,000)

02 Medium size city (population 50,000-250,000)

03 Suburb of a large or medium size city

04 Small city (population 10,000-50,000)

05 Town/village or unincorporated area

98 Refuse to Answer

DEM20. Did you grow up in the Chicago area?

01 Yes - Skip to DEM23

02 No

98 Refuse to Answer

DEM21 How old were you when you moved to the Chicago area?

Enter Age

98 Refuse to Answer


DEM22 Is Chicago the first large central city you have lived in?

01 Yes

02 No

98 Refuse to Answer

DEM23. Financial History

How stressed were you about money growing up?

01 Not at all

02 Slightly

03 Somewhat

  1. A good deal

05 Extremely

98 Refuse to Answer

DEM24. Sexuality

Do you think of yourself as (Choose one)

01 Heterosexual or "Straight"

02 Homosexual, Gay, or Same gender loving

03 Bisexual

04 Other

98 Refuse to Answer


DEM25. Identity

Do you identify with any of the following terms? (Check all that apply)

01 Queer

02 Same gender loving

03 Bisexual

04 In the life

05 On the down low

06 Other –Go to DEM26

07 None

98 Refuse to Answer

DEM26. Identity Specify “other.”_______________


DEM 27. Participation in Community Based Services


In the past 3 months have you participated in any of the following community based or community organized activities?


  1. Yes

  2. No

98 Refuse to Answer


Enter a Yes or No for each of the following.


  1. Howard Brown HIV services

  2. Chicago Public Health Department HIV Testing

  3. Chicago BMX/Black Men’s Xchange

  4. South Side Help Center

  5. Brothers Health Collective

  6. Center on Halstead

  7. Broadway Youth Center

  8. Taskforce Prevention & Community Services

  9. Beyond Care


General Health

Module B: GH - Physical and Mental Health

GH1. In general, what do you consider your health to be? (Choose one)

01 Poor

02 Fair

03 Good

04 Excellent

98 Refuse to Answer

GH2. Do you have a regular doctor or health care provider?

01 Yes

02 No

98 Refuse to Answer

GH3. What kind of health insurance or medical coverage do you currently have?

(Choose one)

01 No medical coverage

02 Medicaid (government insurance for people with low incomes)

03 Medicare (government insurance for the elderly and disabled)

04 Tricare, formerly known as CHAMPUS (e.g., Government insurance for military personnel)

05 Veterans Administration coverage

06 Private health insurance (e.g., HMO, Blue Cross, other employer-based health plan)

98 Refuse to Answer

GH4. In the last 3 months, approximately how many days did you feel sad or depressed for most of the day?

01 Never

02 a couple of days

03 less than a week

04 for a couple of weeks

05 for about a month

06 more than a month

98 Refuse to Answer

GH5. Have you ever been told by a doctor or psychiatrist that you have a mental illness?

01 Yes

02 No – SKIP TO STD 1

98 Refuse to Answer


GH5a. What was the diagnosis? (Check all that apply)

01 Major Depression

02 Anxiety disorder

03 Bipolar disorder

04 Schizophrenia

05 Other specify

98 Refuse to Answer

GH6. Have you ever been hospitalized because of your mental illness?

01 Yes

02 No

98 Refuse to Answer

GH7. Has a doctor prescribed you medication to treat this mental illness?

01 Yes

02 No – SKIP TO STD 1

98 Refuse to Answer

GH8. Are you currently taking the medication as the doctor prescribed?

01 Yes

02 No

98 Refuse to Answer


Sexually Transmitted Diseases

Module C: STD - Sexually Transmitted Diseases

Please answer the following questions as best as you can.

STD1. Have you ever had a sexually transmitted disease (STD)?

01 Yes

02 No - Skip to STD5.

98 Refuse to Answer

STD2. In your lifetime, have you ever been told by a health-care provider that you had a sexually transmitted disease (STD) such as gonorrhea (GC, clap), syphilis, Chlamydia, genital warts, herpes, or hepatitis B?

01 Yes

02 No - Skip to STD5.

98 Refuse to Answer

STD3. Which STDs has a health care provider told you that you had?

(Check all that apply)

01 Gonorrhea (GC, Clap)

02 Chlamydia

03 Syphilis ("Bad blood")

04 Genital Warts (anal, penile) (Human Papilloma Virus)

05 Genital Herpes (anal, penile) (Herpes Simplex Virus)

06 Hepatitis B

07 Hepatitis C

08 Other

09 Don't Know

98 Refuse to Answer

STD4. When was the last time that a health care provider told you that you had a STD?

01 Less than 1 year ago

02 1 – 2 years ago

03 3 – or more years ago

98 Refuse to Answer

The next question will help us understand more about your risk of getting an STD.

STD5. Is your penis circumcised or cut?

01 Yes

02 No

98 Refuse to Answer

HIV Testing (Includes perceived risk)

Module D: HT-HIV Testing

We are interested in knowing about your HIV testing history.

HT1. Have you ever been tested for HIV?

01 Yes

02 No - Skip to HT6.

98 Refuse to Answer

HT2. How many times in your life have you been tested for HIV?

01 ______ - if 0 Skip to HT6

98 Refuse to Answer

HT3. When did you have your first HIV test? (Please take your best guess at the month, if you do not remember the exact month)

MM/YYYY

98 Refuse to Answer (Year)

HT4. 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/YYYY

98 Refuse to Answer (Year)

If HT4 is less than HT3 then The date you entered as your most recent HIV test came before the date of your first HIV test. Please check your responses." Skip to instruction before HT4.

HT5. What was the result of your most recent HIV test? (Choose one)

01 Negative - Skip to HT8.

02 Positive - Skip to HT7.

03 Did not get the result of the last test - Skip to HT8.

04 Indeterminate (neither positive or negative) - Skip to HT8.

98 Refuse to Answer - Skip to HT8.

HT6. What are the reasons why you have not taken an HIV test? (Check all that apply)

01 I'm afraid I might be HIV positive

02 I'm afraid my result will be reported to the government

03 I'm afraid people might suspect that I'm gay or homosexual

04 I'm afraid people might treat me differently

05 I don't have the time

06 I can't afford it

07 I can't get to test site

08 I have been practicing safe sex

09 I know my partners don't have HIV

10 I am not at risk for HIV

11 It is not important

12 I don't know where to get tested

13 My doctor never recommended I get an HIV test

14 Other

98 Refuse to Answer

HT7. When did you first test positive for HIV?

MM/YYYY

98 Refuse to Answer (Year)

If HT7 is less than HT3 and HT2 is equal to 1 or HT7 is less than HT3 and HT2 is greater than 1 or HT7 is greater than HT4 then The date you entered as the first time you tested positive for HIV happened either before your first HIV test date or after your most recent test date. Please check your responses.”

HT8. How likely is it that you are infected with HIV now? (Click on a number)

01 Extremely unlikely

02

03

04

05

06

07

08

09

10 Extremely likely

98 Refuse to Answer

HT9. How likely do you think it is that you will become infected with HIV in your lifetime? (Click on a number)

01 Extremely unlikely

02

03

04

05

06

07

08

09

10 Extremely likely

98 Refuse to Answer

Sexual Assessment (Includes perceived risk)

Module E: SA - SEXUAL ASSESSMENT

The next items are about sexual relationships you have had and/or are having and views you have about sexual relationships.

SA1. How old were you when you first had anal sex (giving or receiving) with a male? (Choose one)

01 Never had anal sex with a man

02 Less than 13 years old

03 13 to 15 years old

04 16 to 18 years old

05 19 to 21 years old

06 22 to 25 years old

07 Older than 25 years old

98 Refuse to Answer

SA2. How old were you when you first had vaginal sex with a female? (Choose one)

01 Never had vaginal sex with a female

02 Less than 13 years old

03 13 to 15 years old

03 16 to 18 years old

04 19 to 21 years old

05 22 to 25 years old

06 Older than 25 years old

98 Refuse to Answer

SA3. How old were you when you first had anal sex with a female? (Choose one)

01 Never had anal sex with a female

02 Less than 13 years old

03 13 to 15 years old

04 16 to 18 years old

05 19 to 21 years old

06 22 to 25 years old

07 Older than 25 years old

98 Refuse to Answer

SA4. How old were you when you first had anal or vaginal sex with a Male-to-female Transgender? (Choose one)

01 Never had anal sex with a Male-to-female Transgender

02 Less than 13 years old

03 13 to 15 years old

04 16 to 18 years old

05 19 to 21 years old

06 22 to 25 years old

07 Older than 25 years old

98 Refuse to Answer


SA5. How important would your close male friends say it is to use a condom when having anal sex with a man? (Choose one)

01 Very important

02 Somewhat important

03 A little important

04 Not at all important

05 They do not have anal sex with men

98 Refuse to Answer

SA6. How important would your close male friends say it is to use a condom when having vaginal sex with a woman? (Choose one)

01 Very important

02 Somewhat important

03 A little important

04 Not at all important

05 They do not have vaginal sex with women

98 Refuse to Answer

SA7. How important would your close male friends say it is to use a condom when having anal sex with a woman? (Choose one)

01 Very important

02 Somewhat important

03 A little important

04 Not at all important

05 They do not have anal sex with women

98 Refuse to Answer

SA8. How important would your close male friends say it is to use a condom when having anal sex with a male-to-female transgender woman? (Choose one)

01 Very important

02 Somewhat important

03 A little important

04 Not at all important

05 They do not have anal or vaginal sex with male-to-female transgender women

98 Refuse to Answer

SA9. In the past 3 months how many male sexual partners have you had?

(Actual Number)

98 Refuse to Answer

SA10. In general my male sexual partners tend to be:

01 1 to 5 years younger

02 6 to 10 years younger

03 More than 10 years younger

04 The same age

03 1 to 5 years older

04 6 to 10 years older

05 More than 10 years older

98 Refuse to Answer


SA11. In the past 3 months how many female sexual partners have you had?

(Actual Number)

98 Refuse to Answer

SA12. In general my female sexual partners tend to be:

01 1 to 5 years younger

02 6 to 10 years younger

03 More than 10 years younger

04 The same age

03 1 to 5 years older

04 6 to 10 years older

05 More than 10 years older

98 Refuse to Answer

SA13. In the past 3 months how many Male-to-Female Transgender sexual partners have you had?

(Actual Number)

98 Refuse to Answer

SA14. In general my Male-to-Females sexual partners tend to be:

01 1 to 5 years younger

02 6 to 10 years younger

03 More than 10 years younger

04 The same age

03 1 to 5 years older

04 6 to 10 years older

05 More than 10 years older

98 Refuse to Answer

SA15. How would you describe your relationship with your most recent male sexual partner? (select one)

01 Boyfriend, Primary Partner or lover

02 Casual partner (friend, fuck buddy, pick-up, acquaintance, one-night stand)

03 Other

98 Refuse to answer

B. The next items are about your PRIMARY male sex partner.

Now we are going to ask you about your Primary sexual partners and sexual behavior. By Primary Sexual Partner we mean someone you consider to be a lover, boyfriend, etc. The next questions are about things you have done in the last 3 months. That is since [insert calculated date]. Please do not count Transgender partners that are men who have used hormones to help them become women or had surgery to give them breasts or a vagina.

SA16. At any time during the past three months, have you been in a committed relationship with another man (this could be a lover or boyfriend or a primary partner)? (Choose one)

01 Yes

02 No - Skip to Section C: Non-Primary Partner.

98 Refuse to Answer


SA17. At any time during the past three months, with how many men have you been in a committed relationship?

(Actual Number)

98 Refuse to Answer

SA18. Are you currently in a committed relationship with a man? (Choose one)

01 Yes

02 No

98 Refuse to Answer

SA19. How many men have you had a committed relationship with in the last 3 months?

(Actual Number)

98 Refuse to Answer

If SA18 = 1: When answering the questions below, think about this current male partner when answering the questions below.

If SA18> or equal to 1 and SA16= 2: When answering the questions below, think about your male ex-partner when answering the questions below.

SA20. How long were you in or had you been in this relationship? (Choose one)

01 Less than 6 months

02 6-11 months

03 1-2 years

04 3-4 years

05 5 or more years

98 Refuse to Answer

SA21. Where did you first meet this partner? Check only one

01 Online hook-up or dating sites or Internet chat rooms

02 A telephone chat line

03 A personal ad in a newspaper or magazine

04 A gay/homosexual bar or club

05 A straight/heterosexual bar or club

06 At a party (not a sex party)

07 At a sex party

08 At a bath house

09 At a bookstore

10 At a public park or restroom

11 On the street

12 Someplace else

13 Other _________ See SA22

98 Refuse to Answer

SA22. Other meeting place specified.

(Actual Place)


SA23. Which racial/ethnic group or groups best describes him? (Check all that apply)

01 Asian

02 American Indian or Alaskan Native

03 Black or African American

04 Latino or Hispanic

05 Native Hawaiian or Pacific Islander

06 White

98 Refuse to Answer

SA24. In the past 3 months, did you live together at any time?

01 Yes

02 No

98 Refuse to Answer

SA25. In the past 3 months, did he help pay for any of your bills, food, or other expenses? (Choose one)

01 He didn't pay for any of the expenses

02 Less than half of the expenses

03 About half of the expenses

04 More than half of the expenses

05 He paid for all of the expenses

98 Refuse to Answer

SA26. In the past 3 months, did you help pay for any of his bills, food, or other expenses? (Choose one)

01 He didn't pay for any of the expenses

02 Less than half of the expenses

03 About half of the expenses

04 More than half of the expenses

05 He paid for all of the expenses

98 Refuse to Answer

The next questions are about anal sex with this primary sex partner.

SA27. In the past 3 months, how many times did you put your penis in his butt?

(Actual Number)

98 Refuse to answer

IF SA27 is equal to 0, then skip to SA29.

SA28. Of the [response to SA27] times you put your penis in his butt in the past 3 months, how many times was a condom used?

(Actual Number)

98 Refuse to answer

SA29. In the past 3 months, how many times did he put his penis in your butt?

(Actual Number)

98 Refuse to answer

IF SA29 is equal to 0, then skip to SA31.

SA30. Of the [response to SA29] times he put his penis in your butt in the past 3 months, how many times was a condom used?

(Actual Number)

98 Refuse to answer


SA31. What is his current HIV status? (Choose one)

01 He has HIV

02 He does not have HIV

03 Don't know/unsure

98 Refuse to Answer

SA32. Did you ask him about his HIV status?

01 Yes

02 No

98 Refuse to Answer

IF SA 31 equals 1 or 2 Skip SA33

SA33. Could you tell me what you think his HIV status is? (Choose one)

01 He has HIV

02 He does not have HIV

98 Refuse to Answer

IF SA33 equal to 98 Skip to SA35

SA34. How did you learn about his HIV status? (Check all that apply)

01 He told me

02 I asked him

03 I guessed based on other things he has talked about

04 I guessed based on things I had seen in his home

05 Someone else told me

06 His physical appearance

07 We got tested together

08 I saw his test results

09 I went with him to get his test results

10 Other

98 Refuse to Answer

SA35. Does he know your HIV status? (Choose one)

01 Yes

02 No

03 Don't know/unsure

98 Refuse to Answer

IF SA35 > 1 Skip SA36 go to Section C

SA36. How did he learn your HIV status? (Check all that apply)

01 I told him

02 He asked me

03 Someone else told him

04 We got tested together

05 He saw my test results

06 He went with me to get my test results

07 Other

98 Refuse to Answer


C. The next items are about CASUAL MALE SEX PARTNERS

SA36a.C. The next items are about CASUAL MALE SEX PARTNERS you may have had in the past 3 months. CASUAL PARTNERS are men you’ve had sex with, but you are NOT in a committed relationship with them. Casual partners could be friends, fuck buddies, pick-ups, acquaintances, one-night stands, or any other man who was not a committed partner. When answering these questions please do not count any boyfriends or main partners you have just told me about.

Intro S367a is for respondents who have primary partner and answered questions in the previous section.

SA36b.C. The next items are about CASUAL MALE SEX PARTNERS you may have had in the past 3 months. CASUAL PARTNERS are men you’ve had sex with, but you are NOT in a committed relationship with them. Casual partners could be friends, fuck buddies, pick-ups, acquaintances, one-night stands, or any other man who was not a committed partner. When answering these questions please do not count any boyfriends or main partners.

SA37. In the last 3 months how many casual male sex partners have you had?

(Actual Number)

98 Refuse to Answer

If SA37 equals 0 Skip to SA45

SA38. In the past 3 months how many causal male sex partners put their penis in your butt without using a condom?

(Actual Number)

98 Refuse to Answer

SA39. In the past 3 months how many different casual male sex partners did you have where you put your penis in their butt without using a condom?

(Actual Number)

98 Refuse to Answer

SA40. In the past three months, how many times did you have anal sex with any casual male sex partners because he gave you drugs, money, a place to stay, or other things you needed?

(Actual Number)

98 Refuse to Answer

SA41. In the past three months, how many casual male partners did you give drugs, money, a place to stay, or other things he needed so he would have sex with you?

(Actual Number)

98 Refuse to Answer


SA42. How many casual male sex partners (with whom you later had anal sex without using a condom) did you meet in the following places? [Actual number for each]

01 Online hook-up or dating sites or Internet chat rooms


02 A telephone chat line

03 A personal ad in a newspaper or magazine

04 A gay/homosexual bar or club

05 A straight/heterosexual bar or club

06 At a party (not a sex party)

07. At a sex party

08. At a bath house

09. At a bookstore

10. At a public park or restroom

11. On the street

12 Other place See SA43

98 Refuse to Answer

SA43. Specify other places

(Actual Answer)

SA44. Which racial/ethnic group or groups best describes any of the casual partners you just described? How many were…. (choose all that apply) [Actual numbers]

01 Asian

02 American Indian or Alaskan Native

03 Black or African American

04 Latino or Hispanic

05 Native Hawaiian or Pacific Islander

06 White

98 Refuse to Answer

Intro is for respondents who answered SA37 equals 0.

SA45. You indicated you have not had a casual male sex partner in the past 3 months. When was the last time you had a casual male sex partner?

01 More than 3 months but not more than 6 months

02 More than 6 months but less than 1 year

03 More than 1 year

04 I have never had a casual male sex partner

98 Refuse to answer

IF SA45 > 1 Skip to Section F.

The next questions are about your most recent encounter with a causal male sex partner –

SA46. During this encounter did you put your penis in his butt?

01 Yes

02 No – (SKIP to SA48)

98 Refuse to Answer

SA47. Did you wear a condom?

01 Yes (Skip to SA49)

02 No

98 Refuse to Answer


SA48. Was a condom available to be used during the encounter?

01 Yes

02 No

03 Don't Know

98 Refuse to Answer

SA49. During this encounter did he put his penis in your butt?

01 Yes

02 No (SKIP to SA51)

98 Refuse to Answer

SA50. Did he wear a condom?

01 Yes (SKIP to SA52)

02 No

98 Refuse to Answer

SA51. Was a condom available to be used during the encounter?

01 Yes

02 No

03 Don't Know

98 Refuse to Answer

SA52. In this sexual encounter, did he give you things you needed (drugs, money, food, etc)?

01 Yes

02 No

98 Refuse to Answer

SA53. In this sexual encounter did you give him things he needed (drugs, money, food, etc)?

01 Yes

02 No

98 Refuse to Answer

SA54. Did you use alcohol or drugs before or during this sexual encounter?

01 Yes

02 No (Skip to SA61)

98 Refuse to Answer

SA55. Were you drunk or buzzed on alcohol during this encounter?

01 Yes

02 No

98 Refuse to Answer

SA56. Did you use marijuana (pot, hash) before or during the encounter?

01 Yes

02 No

98 Refuse to Answer

SA57. Did you snort or smoke cocaine/crack before or during the encounter?

01 Yes

02 No

98 Refuse to Answer


SA58. Did you use club drugs (for example, crystal meth, ecstasy, GHB, special K) before or during the encounter?

01 Yes

02 No

98 Refuse to Answer

SA59. Did you use Viagra, Levitra, or Cialis before or during the encounter?

01 Yes

02 No

98 Refuse to Answer

SA60. Did you use poppers before or during the encounter?

01 Yes

02 No

98 Refuse to Answer

SA61. To the best of your knowledge, did the person you had sex with use any alcohol before or during the encounter?

01 Yes

02 No

98 Refuse to Answer

SA62. To the best of your knowledge, did the person you had sex with use drugs before or during the encounter?

01 Yes

02 No

98 Refuse to Answer

IF SA46 and SA49 equals 2 Skip to SA65

SA63. Did you tell him your HIV status before you had anal sex with him in this encounter?

01 Yes

02 No

98 Refuse to Answer

SA64. Did he tell you his HIV status before you had anal sex with him in this encounter?

01 Yes

02 No (Skip to SA65)

98 Refuse to Answer

SA65. What did he say about his HIV status? (Choose one)

01 He had HIV

02 He did not have HIV

03 He did not know his HIV status

98 Refuse to Answer

IF SA65 equals 1, 2 or 3 Skip to SA67

SA66. Did you ask him about his HIV status? (Choose one)

01 Yes

02 No

98 Refuse to Answer


SA67. At the time of the encounter did you think.....? (Choose one)

01 He had HIV

02 He did not have HIV

03 I was unsure of his HIV status

98 Refuse to Answer

F. The next questions ask you about any sexual activity you may have had with MALE-TO-FEMALE TRANSGENDER PERSONS.

By transgender we mean men who have used hormones to help them become women or had surgery to give them breasts or a vagina.

SA68. Have you had anal or vaginal intercourse with a male-to-female transgender in the past 3 months?

01 Yes

02 No

98 Refuse to Answer

IF SA68 is equal to 2, then skip to SA72

SA69. In the past 3 months, with how many transgender persons did you put your penis in their butt without using a condom?

Actual Number

98 Refuse to Answer

SA70. In the past 3 months, how many transgender persons put their penis in your butt without using a condom?

Actual Number

98 Refuse to Answer

SA71. In the past 3 months, with how many transgender persons did you put your penis in their vagina without using a condom?

Actual Number

98 Refuse to Answer

G. The next questions ask you about sexual activity you have had with any FEMALE PARTNER(S).

SA72. Have you ever had a female sex partner?

01 Yes

02 No – Skip to KHIVTS1.

98 Refuse to Answer

SA73. When did you most recently have sex with a female?

01 Within the past week

02 Within the past month

03 Within the past 3 months

04 Within the past 6 months

05 Within the past year

06 Within the past 5 years

07 More than 5 years ago

98 Refuse to Answer


SA74. Were you in a committed relationship (girlfriend, lover, or primary partner) with this most recent female sexual partner? (Choose one)

01 Yes

02 No

98 Refuse to Answer

SA75. Are you currently in a committed relationship with this female? (Choose one)

01 Yes

02 No

98 Refuse to Answer

IF SA75 equals 2 Skip to SA77

SA76. How long were you in or have been in this relationship? (Choose one)

01 Less than 6 months

02 6-11 months

03 1-2 years

04 3-4 years

05 5 or more years

98 Refuse to Answer

The following items ask you about your most recent female sexual relationship.

SA77. Which racial/ethnic group or groups best describes her? (Check all that apply)

01 Asian

02 American Indian or Alaskan Native

03 Black or African American

04 Latino or Hispanic

05 Native Hawaiian or Pacific Islander

06 White

98 Refuse to Answer

SA78. In the past 3 months, did you live together at any time?

01 Yes

02 No

98 Refuse to Answer

SA79. In the past 3 months, did she help pay for any of your bills, food, or other expenses? (Choose one)

01 She didn't pay for any of the expenses

02 Less than half of the expenses

03 About half of the expenses

04 More than half of the expenses

05 She paid for all of the expenses

98 Refuse to Answer

SA80. In the past 3 months how many times did you have vaginal sex with her (or put your penis in her vagina)?

Actual Number

98 Refuse to Answer

If SA80 is equal to 0, then skip to SA82.


SA81. Of those [response to SA80] times you had vaginal sex with her, how many times did you use a condom from start to finish?

(Actual Number)

98 Refuse to Answer

SA82. How many times did you have anal sex with her (or put your penis in her butt)?

(Actual Number)

98 Refuse to Answer

IF SA82 is equal to 0, then skip to SA84.

SA83. Of those [response to SA82] times you had anal sex with her, how many times did you use a condom from start to finish?

(Actual Number)

98 Refuse to Answer

SA84. Did you ask her about her HIV status?

01 Yes

02 No

98 Refuse to Answer

SA85. What is her current HIV status? (Choose one)

01 She has HIV

02 She does not have HIV

03 Don't know/unsure

98 Refuse to Answer

IF S85 is equal to 1 or 2, then skip to SA87.

SA86. Could you tell me what you think her HIV status is? (Choose one)

01 She has HIV

02 She does not have HIV

98 Refuse to Answer

SA87. How did you learn about her HIV status? (Check all that apply)

01 She told me

02 I asked

03 I guessed based on other things she has talked about

04 I guessed based on things I had seen in her home

05 Someone else told me

06 Her physical appearance

07 We got tested together

08 I saw her test results

09 I went with her to get her test results

10 Other

98 Refuse to Answer

SA88. Does she know your HIV status?

01 Yes

02 No

03 Don't Know

98 Refuse to Answer

IF SA88 is equal to 2 or 3 than skip to SA90


SA89. How did she learn your HIV status? (Check all that apply)

01 I told her

02 She asked

03 Someone else told her

04 We got tested together

05 She saw my test results

06 She went with me to get my test results

07 Other

98 Refuse to Answer

SA90. Have you told her that you have had sex with a man?

01 Yes

02 No

98 Refuse to Answer

Sexual Behavior

Module F: SBD - Sexual Behavior Disclosure

SBD1. At the present time, how close do you feel to your mother or the woman who raised you? (Choose one)

01 Very Close

02 Somewhat Close

03 Not Close

04 At the present time I do not have this type of person in my life

05 She passed away

98 Refuse to Answer

SBD2. At the present time, how close do you feel to your father or the man who raised you? (Choose one)

01 Very Close

02 Somewhat Close

03 Not Close

  1. At the present time I do not have this type of person in my life

  2. 05 He passed away

98 Refuse to Answer

SBD3. At the present time, how close do you feel to your brother(s)? (If you have more than one brother, answer by thinking of the one you feel closest to) (Choose one)

01 Very Close

02 Somewhat Close

03 Not Close

04 At the present time I do not have this type of person in my life

98 Refuse to Answer

SBD4. At the present time, how close do you feel to your sister(s)? (If you have more than one sister, answer by thinking of the one you feel closest to) (Choose one)

01 Very Close

02 Somewhat Close

03 Not Close

04 At the present time I do not have this type of person in my life

98 Refuse to Answer

SBD5. At the present time, how close do you feel to your minister or priest?

(Choose one)

01 Very Close

02 Somewhat Close

03 Not Close

04 I don't have this type of person in my life

98 Refuse to Answer

SBD6. At the present time, how close do you feel to your straight friends? (Choose one)

01 Very Close

02 Somewhat Close

03 Not Close

04 I don't have this type of person in my life

98 Refuse to Answer

SBD7. At the present time, how close do you feel to your homosexual friends? (Choose one)

01 Very Close

02 Somewhat Close

03 Not Close

04 I don't have this type of person in my life

98 Refuse to Answer

SBD8. At the present time, how close do you feel to your doctor? (Choose one)

01 Very Close

02 Somewhat Close

03 Not Close

04 I don't have this type of person in my life

98 Refuse to Answer

SBD9. Have you told at least one person that you have sex with men?

01 Yes

02 No – Skip to SBD12

98 Refuse to Answer

SBD10. Who have you told that you have sex with men? (Check all that apply) (Check all that apply)

01 My mother or the woman who raised me

02 My father or the man who raised me

03 My brother(s)

04 My sister(s)

05 My minister or priest

06 My straight/heterosexual friends

07 My gay/homosexual friends

08 My doctor (or other health or mental health provider)

98 Refuse to Answer

SBD11. About how many of your friends know that you have sex with men?

(Choose one)

01 All

02 More than half

03 About half

04 Less than half

05 None

98 Refuse to Answer

SBD12. How important is it for you that people who are close to you know that you have sex with men? (Choose one)

01 Very important

02 Somewhat important

03 A little important

04 Not at all important

98 Refuse to Answer


SBD13. Generally, how important is it for you to keep your sexual relationships with men secret? (Choose one)

01 Very important

02 Somewhat important

03 A little important

04 Not at all important

98 Refuse to Answer

Knowledge of HIV Treatment

Module G: KHIVTS - Knowledge of HIV Treatment Scale

KHIVTS1. People with HIV who take HIV medications are less likely to infect their sex partners during unsafe sex.

01. Strongly Disagree

02. Disagree

03. Agree

04. Strongly Agree

98. Refuse to Answer

KHIVTS2. HIV treatment makes it easier to relax about unsafe sex

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer

KHIVTS3. It is safe to have sex without a condom when a person’s viral load is undetectable.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer

KHIVTS4. HIV treatments take the worry out of sex.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer

KHIVTS5. People with an undetectable viral load don’t need to worry about infecting others with HIV.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer


Imagine that an HIV negative man has sex with an HIV positive man who is not being treated for his HIV infection. Please rate how risky you believe each sexual activity is for the HIV negative partner.

KHIVTS6. Anal sex with no condom when the HIV negative partner is bottom.

01Very Low Risk

02 Low Risk

03 Moderate Risk

04 High Risk

05 Very High Risk

98 Refuse to Answer

KHIVTS7. Anal sex with no condom when the HIV negative partner is top.

01 Very Low Risk

02 Low Risk

03 Moderate Risk

04 High Risk

05 Very High Risk

98 Refuse to Answer

Now imagine that an HIV negative man has sex with an HIV positive man who is being treated for his HIV infection with anti-viral medications. Rate how risky you believe each activity is for the HIV negative partner.

KHIVTS8. Anal sex with no condom when the HIV negative partner is bottom.

01 Very Low Risk

02 Low Risk

03 Moderate Risk

04 High Risk

05 Very High Risk

98 Refuse to Answer

KHIVTS9. Anal sex with no condom when the HIV negative partner is a top.

01 Very Low Risk

02 Low Risk

03 Moderate Risk

04 High Risk

05 Very High Risk

98 Refuse to Answer

Now imagine that an HIV negative man has sex with an HIV positive man who is being treated for his HIV infection with anti-viral medications and his viral load is undetectable. Rate how risky you believe each activity is for the HIV negative partner.

KHIVTS11. Anal sex with no condom when the HIV negative partner is bottom.

01 Very Low Risk

02 Low Risk

03 Moderate Risk

04 High Risk

05 Very High Risk

98 Refuse to Answer


KHIVTS12. Anal sex with no condom when the HIV negative partner is top.

01 Very Low Risk

02. Low Risk

03 Moderate Risk

04 High Risk

05 Very High Risk

98 Refuse to Answer

The next questions ask what you think your chances are of getting HIV/AIDS. Please circle the number that best describes what you think. If you have tested HIV positive, answer these questions regarding what you think your risk is for getting a sexually transmitted disease (STD).

KHIVTS13. Based on your sexual life from the last 6-months, how much do you think you are at risk for HIV/AIDS?

01 Not at Risk at all

02 Slight Risk

03 Somewhat at Risk

04 Good Deal at Risk

05 Great Deal at Risk

06 Extremely Risky

98 Refuse to Answer

KHIVTS14. How much risk do you think your friends are at for HIV/AIDS?

01 Not at Risk at all

02 Slight Risk

03 Somewhat at Risk

04 Good Deal at Risk

05 Great Deal at Risk

06 Extremely Risky

98 Refuse to Answer

KHIVTS15. Think about the number of men in your community that have HIV. For every 1,000 men in your community, how many do you think are infected with HIV? Have HIV/AIDS

01(Actual Number)

02 I don’t Know

98 Refuse to Answer


PrEP/PeP


Module H: PrEP- PREP/PEP Items

If HT5 equals 2 Skip to PrEP10

HIV-Negative and Unknown Status Participants


PrEP1. Before today, have you heard about pre-exposure prophylaxis or PrEP?

01 Yes

02 No

98 Refuse to Answer

PrEP2. 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 for the rest of your life (or as long as you are sexually active) to try to protect yourself from becoming infected with HIV?

01 Yes

02 No

98 Refuse to Answer

PrEP3. Have you ever used an anti-HIV medication before sex because you thought it might prevent HIV transmission between you and your sex partner?

01 Yes

02 No – Skip to PrEP7

03 Don't Know

98 Refuse to Answer

PrEP4. How many times have you done this in the past year?

01 times per year

02 Don't Know

98 Refuse to Answer

PrEP5. How long have or did you take the medication this time? (Choose one)

01. One day or less

02. 2 - 6 days

03. 1 week but less than 1 month

04. 1 month or longer

05 Don't Know

98 Refuse to Answer

PrEP6. How did you obtain the anti-HIV medication?

01 Health care provider (prescription, sample, etc

02 Sexual Partner

03 Friend

04 Internet

05 Other (Please describe) _______________________________

98 Refuse to Answer

PrEP7. Have you ever used an anti-HIV medication only after sex because you thought it might prevent HIV transmission between you and your sex partner?

01 Yes

02 No – Skip to PrEP10

03 Don't Know

98 Refuse to Answer

PrEP8. How many times have you done this in the past year?

01 times per year

02 Don't Know

98 Refuse to Answer

PrEP9. How long have or did you take the medication after having unprotected sex? (Choose one)

01. One day or less

02. 2 - 6 days

03 1 week but less than 1 month

04 1 month or longer

05. Don't Know

98 Refuse to Answer

If HT5 equals 1, 3, or 4 Skip to Module I: CUSE - Condom Use Self-Efficacy

Only HIV+ status Participants respond to PrEP10

PrEP10. Have you ever given anti-HIV medication to a sex partner before sex because you thought it might prevent HIV infection?

01 Yes

02 No - Skip to PrEP13

03 Don't Know

98 Refuse to Answer

PrEP11. How many times have you done this in the past year?

01 times per year

02 Don't Know

98 Refuse to Answer

PrEP12. At that time, how much medication did you give them? Enough for... (Choose one)

01 One day or less

02 2 - 6 days

03 1 week but less than 1 month

04 1 month or longer

05 Don't Know

98 Refuse to Answer

PrEP13. Have you ever given anti-HIV medication to a sex partner only after sex because you thought it might prevent HIV infection?

01 Yes

02 No – Skip to CS

03 Don't Know

98 Refuse to Answer



PrEP14. How many times have you done this in the past year?

01 times per year

02 Don't Know

98 Refuse to Answer

PrEP15. At that time, how much medication did you give them? Enough for... (Choose one)

01 One day or less

02 2 - 6 days

03 1 week but less than 1 month

04 1 month or longer

05 Don't Know

98 Refuse to Answer

Condom Use Self Efficacy


Module I: CUSE - Condom Use Self-Efficacy


CUSE1. In general, how much of a problem would it be for you to put a condom on your hard penis prior to having sex?

01 None

02 Not much

03 A little

04 Some

05 A lot

98 Refuse to answer

CUSE2. How much of a problem would it be for you to unroll a condom down correctly on the first try?

01 None

02 Not much

03 A little

04 Some

05 A lot

98 Refuse to answer

CUSE3. 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 prior to having sex?

01 None

02 Not much

03 A little

04 Some

05 A lot

98 Refuse to answer

CUSE4. How much of a problem would it be for you to unroll a condom fully to the base of your penis?

01 None

02 Not much

03 A little

04 Some

05 A lot

98 Refuse to answer

CUSE5. How much of a problem would it be for you to squeeze air from the tip of a condom?

01 None

02 Not much

03 A little

04 Some

05 A lot

98 Refuse to answer


CUSE6. How much of a problem would it be for you to take a condom off without spilling the semen?

01 None

02 Not much

03 A little

04 Some

05 A lot

98 Refuse to answer

CUSE7. How much of a problem would it be for you to take a condom off before you lose your erection?

01 None

02 Not much

03 A little

04 Some

05 A lot

98 Refuse to answer

CUSE8. How much of a problem would it be for you to dispose of a used condom?

01 None

02 Not much

03 A little

04 Some

05 A lot

98 Refuse to answer

CUSE9. How much of a problem would it be for you to use a spermicidal/lubricant with a condom?

01 None

02 Not much

03 A little

04 Some

05 A lot

98 Refuse to answer

Contemplation Ladder – Condoms During Anal Sex (M/F versions) Use


Module J: Contemplation Ladder - Condoms During Anal Sex (Female partners)


CFLPFS Contemplation Ladder - Condoms During Anal Sex (Female partners) Screening item : In the past year (12 months) have you had vaginal or anal sex with a female partner other than a primary female partner?


01 – No – Skip to CFLPMS

02 - Yes

98. Refuse to Answer


CFLPFS. Each rung on this ladder represents the way a person may relate to the idea of using condoms during anal or vaginal sex with casual female partners. Select the number that best represents where you are now.


01. I have used condoms regularly and will never go back to having unprotected anal sex.

02. I have used condoms more frequently, but I still worry about slipping back to having unprotected anal/vaginal sex.

03. I still plan to have anal/vaginal sex without condoms, but I'll make some changes like cutting back how often I do it.

04. I definitely plan to use condoms for anal/vaginal sex more often, and I'm almost ready to make some plans about how to do it.

05. I definitely plan to use condoms for anal/vaginal sex more often, but I'm not ready to make any plans to do it.

06. I often have anal/vaginal sex with condoms, but I have no plans to use them more often .

07. I sometimes have anal/vaginal sex with condoms, but I have no plans to use them more often.

08. I rarely have anal/vaginal sex with condoms and I have no plans to use them.

9. I never have anal/vaginal sex with condoms and have no plans to use them.

10. I enjoy anal/vaginal sex without condoms and have decided to never change it. I have no interest in using condoms.



Module J: Contemplation Ladder - Condoms During Anal Sex (Male partners


CFLPMS Contemplation Ladder - Condoms During Anal Sex (Male partners) Screening item : In the past 90-days have you had anal sex with a male partner other than a primary male partner?

01 - No – Skip to Next Section DBCU1

02 – Yes

98. Refuse to Answer


CFLPMS Each rung on this ladder represents the way a person may relate to the idea of using condoms during anal sex with casual male partners. Select the number that best represents where you are now.


01. I have used condoms regularly and will never go back to having unprotected anal sex.


02. I have used condoms more frequently, but I still worry about slipping back to having unprotected anal sex.


03. I still plan to have anal sex without condoms, but I'll make some changes like cutting back how often I do it .


04. I definitely plan to use condoms for anal sex more often, and I'm almost ready to make some plans about how to do it.


05. I definitely plan to use condoms for anal sex more often, but I'm not ready to make any plans to do it.


06. I often have anal sex with condoms, but I have no plans to use them more often .


07. I sometimes have anal sex with condoms, but I have no plans to use them more often.


08. I rarely have anal sex with condoms and I have no plans to use them.


09. I never have anal sex with condoms and have no plans to use them.


10. I enjoy anal sex without condoms and have decided to never change it. I have no interest in using condoms.

Decisional Balance for Condom Use


Module K: DBCU - Decisional Balance for Condom Use


When you think about having sex with or without condoms, how important are any of the following statements to you, when making your decisions to use or not use condoms.


DBCU1. Sex without a condom is more spontaneous.

01 Not at all

02 Slightly

03 Moderately

04 Very

05 Extremely

98 Refuse to Answer


DBCU2. I could get infected (or) re-infected with HIV if I have sex without a condom.

01 Not at all

02 Slightly

03 Moderately

04 Very

05 Extremely

98 Refuse to Answer


DBCU3. Not using a condom with a partner shows that person I trust them.

01 Not at all

02 Slightly

03 Moderately

04 Very

05 Extremely

98 Refuse to Answer


DBCU4. It feels better to have sex without a condom.

01 Not at all

02 Slightly

03 Moderately

04 Very

05 Extremely

98 Refuse to Answer


DBCU5. Sex without a condom feels more natural.

01 Not at all

02 Slightly

03 Moderately

04 Very

05 Extremely

98 Refuse to Answer


DBCU6. I feel guilty after having sex without condom.

01 Not at all

02 Slightly

03Moderately

04 Very

05 Extremely

98 Refuse to Answer


DBCU7. It’s easier for me to cum when I have sex without a condom.

01 Not at all

02 Slightly

03 Moderately

04 Very

05 Extremely

98 Refuse to Answer


DBCU8. It’s easier to keep my hard-on/stay lubricated when I have sex without a condom.

01 Not at all.

02 Slightly

03 Moderately

04 Very

05 Extremely

98 Refuse to Answer


DBCU9. I would feel bad if my friends found out I had sex without a condom.

01 Not at all

02 Slightly

03 Moderately

04 Very

05 Extremely

98 Refuse to Answer


DBCU10. Having sex without a condom is more exciting because I’ve been told I shouldn’t do it.

01 Not at all

02 Slightly

03 Moderately

04 Very

05 Extremely

98 Refuse to Answer


DBCU11. I don’t like to have a barrier between me and my partners when we have sex.

01 Not at all

02 Slightly

03 Moderately

04 Very

05 Extremely

98 Refuse to Answer

DBCU12. Not using a condom for sex makes me feel really irresponsible.

01 Not at all

02 Slightly

03 Moderately

04 Very

05 Extremely

98 Refuse to Answer


DBCU13. When my partner doesn’t want to use a condom, I want to give that person what he/she wants.

01 Not at all

02 Slightly

03 Moderately

04 Very

05 Extremely

98 Refuse to Answer


DBCU14. Having a sex without a condom is like showing a partner I don’t care what happens to him/her.

01 Not at all

02 Slightly

03 Moderately

04 Very

05 Extremely

98 Refuse to Answer


DBCU15. It feels wrong to have sex without a condom.

01 Not at all

02 Slightly

03 Moderately

04 Very

05 Extremely

98 Refuse to Answer


DBCU16. Using condoms reminds me of HIV.

01 Not at all

02 Slightly

03 Moderately

04 Very

05 Extremely

98 Refuse to Answer



DBCU17. Just knowing that sex without a condom can be dangerous is a turn on.

01 Not at all

02 Slightly

03 Moderately

04 Very

05 Extremely

98 Refuse to Answer


Self-Efficacy Condom Use


Module L: SECU- Self-Efficacy Condom Use


SECOND1. How confident are you that you could avoid having sex without a condom when you really want sex?

01 Not at all confident

02 Not very confident

03 Somewhat confident

04 Very confident

05 Extremely confident

98 Refuse to Answer


SECOND2. How confident are you that you could avoid having sex without a condom when you really need affection?

01 Not at all confident

02 Not very confident

03 Somewhat confident

04 Very confident

05 Extremely confident

98 Refuse to Answer


SECOND3. How confident are you that you could avoid having sex without a condom when you are with someone who is really hot?

01 Not at all confident

02 Not very confident

03 Somewhat confident

04 Very confident

05 Extremely confident

98 Refuse to Answer


SECOND4. How confident are you that you could avoid having sex without a condom when he/she says he/she does not want to use a condom?

01 Not at all confident

02 Not very confident

03 Somewhat confident

04 Very confident

05 Extremely confident

98 Refuse to Answer



SECOND5. How confident are you that you could avoid having sex without a condom when you are angry?

01 Not at all confident

02 Not very confident

03 Somewhat confident

04 Very confident

05 Extremely confident

98 Refuse to Answer


SECOND6. How confident are you that you could avoid having sex without a condom when you think the risk of STDs is low?

01 Not at all confident

02 Not very confident

03 Somewhat confident

04 Very confident

05 Extremely confident

98 Refuse to Answer


SECOND7. How confident are you that you could avoid having sex without a condom when you think the risk for HIV (or re-infection) is low?

01 Not at all confident

02 Not very confident

03 Somewhat confident

04 Very confident

05 Extremely confident

98 Refuse to Answer


SECOND8. How confident are you that you could avoid having sex without a condom when you feel depressed?

01 Not at all confident

02 Not very confident

03 Somewhat confident

04 Very confident

05 Extremely confident

98 Refuse to Answer


SECOND9. How confident are you that you could avoid having sex without a condom when you think that he/she does not want to use condoms?

01 Not at all confident

02 Not very confident

03 Somewhat confident

04 Very confident

05 Extremely confident

98 Refuse to Answer



SECOND10. How confident are you that you could avoid having sex without a condom when you are drunk or high on drugs?

01 Not at all confident

02 Not very confident

03 Somewhat confident

04 Very confident

05 Extremely confident

98 Refuse to Answer


SECOND11. How confident are you that you could avoid having sex without a condom when you think stopping to get a condom will spoil the mood?

01 Not at all confident

02 Not very confident

03 Somewhat confident

04 Very confident

05 Extremely confident

98 Refuse to Answer


SECOND12. How confident are you that you could avoid having sex without a condom when you are really sexually aroused?

01 Not at all confident

02 Not very confident

03 Somewhat confident

04 Very confident

05 Extremely confident

98 Refuse to Answer


SECOND13. How confident are you that you could avoid having sex without a condom when you really want to see or be with her/him again?

01 Not at all confident

02 Not very confident

03 Somewhat confident

04 Very confident

05 Extremely confident

98 Refuse to Answer


SECOND14. How confident are you that you could avoid having sex without a condom when your partner doesn't know that you are bisexually-active?

01 Not at all confident

02 Not very confident

03 Somewhat confident

04 Very confident

05 Extremely confident

98 Refuse to Answer

HIV Stigma for Positive Men – Negative Self Esteem Subscale


Module M: HVPOSS- HIV Stigma - Negative Self-Esteem Subscale of the HIV Stigma Scale

FOR HIV-Positive Men

If HT1 is equal to 2 or HT5 is equal to 1 Skip to HNEGS1.


HPOSS1. I feel guilty because I have HIV.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer


HPOSS2. People’s attitudes about HIV make me feel worse about myself.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer


HPOSS3. I work hard to keep my HIV a secret.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer


HPOSS4. I feel I am not as good a person as others because I have HIV.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer


HPOSS5. I never feel ashamed of having HIV.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer



HPOSS6. It is easier to avoid new friendships than worry about telling someone that I have HIV.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer


HPOSS7. Having HIV makes me feel unclean.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer


HPOSS8. Since learning I have HIV, I feel set apart and isolated from the rest of the world.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer


HPOSS9. Having HIV makes me feel that I’m a bad person.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer


HPOSS10. Having HIV in my body is disgusting to me.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer


HPOSS11. As a rule, telling others that I have HIV has been a mistake.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer



HPOSS12. People who know I have HIV tend to ignore my good points.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer


HPOSS13. People seem afraid of me once they learn I have HIV.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer


If HT5 is equal to 2 Skip to DCSHSPOS1.




HIV Stigma for Negative Men – Disclosure Concerns Subscale


Module N: HNEGS- HIV Stigma - Negative Self-Esteem Subscale of the HIV Stigma Scale

FOR HIV-Negative Men


HNEGS1. I would feel guilty if I got HIV.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer


HNEGS2. People’s attitudes about HIV would make me feel worse about myself.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer


HNEGS3. I would work hard to keep my HIV a secret.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer


HNEGS4. I would feel I am not as a good a person as others because I have HIV.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer


HNEGS5. I would never feel ashamed of having HIV.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer


HNEGS6. It would be easier to avoid new friendships than worry about telling someone that I have HIV.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer

HNEGS7. Getting HIV would make me feel unclean

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer


HNEGS8. Upon learning I got HIV, I would feel set apart and isolated from the rest of the world.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer


HNEGS9. Getting HIV would make me feel that I’m a bad person.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer


HNEGS10. Having HIV in my body would be disgusting to me

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer


HNEGS11. Telling others that I got HIV would be a mistake.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer


HNEGS12. People who found out I got HIV would be likely to ignore my good points.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer



HNEGS13. People would act afraid if they learned I have HIV.

01 Strongly Disagree

02 Disagree

03 Agree

04 Strongly Agree

98 Refuse to Answer

Sexual Communication


Module O: SCSEP -Sexual Communication Self-Efficacy with a Partner


The next items are about ways you talk to sexual partners about sex.


SCSEP1. How hard is it for you to ask how many sex partners he has had?

01 Very hard

02 Hard

03 Easy

04 Very easy

98 Refuse to answer


SCSEP2. How hard is it for you to ask if he is having sex with you and other men?

01 Very hard

02 Hard

03 Easy

04 Very easy

98 Refuse to answer


SCSEP3. How hard is it for you to ask if he is having sex with you and other women?

01 Very hard

02 Hard

03 Easy

04 Very easy

98 Refuse to answer


SCSEP4. How hard is it for you to ask if he has an STD?

01 Very hard

02 Hard

03 Easy

04 Very easy

98 Refuse to answer


SCSEP5. How hard is it for you to ask if he could use a condom?

01 Very hard

02 Hard

03 Easy

04 Very easy

98 Refuse to answer


SCSEP6. How hard is it for you to demand that he use a condom?

01 Very hard

02 Hard

03 Easy

04 Very easy

98 Refuse to answer


SCSEP7. How hard is it for you to refuse to have sex if he won't wear a condom?

01 Very hard

02 Hard

03 Easy

04 Very easy

98 Refuse to answer


Collective Self Esteem


Module P: Collective Self Esteem Scale


CSES1. I am a worthy/valued member of my race/ethnic group.

01. Strongly disagree

02. Disagree

03. Disagree somewhat

04. Neutral

05. Agree somewhat

06. Agree

07. Strongly agree

98. Refuse to Answer


CSES2. I often regret that I belong to my racial/ethnic group.

01. Strongly disagree

02. Disagree

03. Disagree somewhat

04. Neutral

05. Agree somewhat

06. Agree

07. Strongly agree

98. Refuse to Answer


CSES3. Overall, my racial/ethnic group is considered good by others.

01. Strongly disagree

02. Disagree

03. Disagree somewhat

04. Neutral

05. Agree somewhat

06. Agree

07. Strongly agree

98. Refuse to Answer


CSES4. Overall, my race/ethnicity has very little to do with how I feel about myself.

01. Strongly disagree

02. Disagree

03. Disagree somewhat

04. Neutral

05. Agree somewhat

06. Agree

07. Strongly agree

98. Refuse to Answer


CSES5. I feel I don't have much to offer to my racial/ethnic group.

01. Strongly disagree

02. Disagree

03. Disagree somewhat

04. Neutral

05. Agree somewhat

06. Agree

07. Strongly agree

98. Refuse to Answer


CSES6. In general, I'm glad to be a member of my racial/ethnic group.

01. Strongly disagree

02. Disagree

03. Disagree somewhat

04. Neutral

05. Agree somewhat

06. Agree

07. Strongly agree

98. Refuse to Answer


CSES7. Most people consider my racial/ethnic group, on the average, to be more ineffective than other groups.

01. Strongly disagree

02. Disagree

03. Disagree somewhat

04. Neutral

05. Agree somewhat

06. Agree

07. Strongly agree

98. Refuse to Answer


CSES8. The racial/ethnic group I belong to is an important reflection of who I am.

01. Strongly disagree

02. Disagree

03. Disagree somewhat

04. Neutral

05. Agree somewhat

06. Agree

07. Strongly agree

98. Refuse to Answer


CSES9. I am a cooperative participant in the activities of my racial/ethnic group.

01. Strongly disagree

02. Disagree

03. Disagree somewhat

04. Neutral

05. Agree somewhat

06. Agree

07. Strongly agree

98. Refuse to Answer


CSES10. Overall, I often feel that my racial/ethnic group is not worthwhile.

01. Strongly disagree

02. Disagree

03. Disagree somewhat

04. Neutral

05. Agree somewhat

06. Agree

07. Strongly agree

98. Refuse to Answer


CSES11. In general, others respect my race/ethnicity.

01. Strongly disagree

02. Disagree

03. Disagree somewhat

04. Neutral

05. Agree somewhat

06. Agree

07. Strongly agree

98. Refuse to Answer


CSES12. My race/ethnicity is unimportant to my sense of what kind of a person I am.

01. Strongly disagree

02. Disagree

03. Disagree somewhat

04. Neutral

05. Agree somewhat

06. Agree

07. Strongly agree

98. Refuse to Answer



CSES13. I often feel I’m a useless/unvalued member of my racial/ethnic group.

01. Strongly disagree

02. Disagree

03. Disagree somewhat

04. Neutral

05. Agree somewhat

06. Agree

07. Strongly agree

98. Refuse to Answer


CSES14. I feel good about the race/ethnicity I belong to.

01. Strongly disagree

02. Disagree

03. Disagree somewhat

04. Neutral

05. Agree somewhat

06. Agree

07. Strongly agree

98. Refuse to Answer


CSES15. In general, others think my racial/ethnic group is unworthy.

01. Strongly disagree

02. Disagree

03. Disagree somewhat

04. Neutral

05. Agree somewhat

06. Agree

07. Strongly agree

98. Refuse to Answer


CSES16. In general, belonging to my race/ethnicity is an important part of my self image.

01. Strongly disagree

02. Disagree

03. Disagree somewhat

04. Neutral

05. Agree somewhat

06. Agree

07. Strongly agree

98. Refuse to Answer



Negative Experiences


Module Q: NE- Negative Experiences


NE1. In the past 12 months, how often have you been hit or beaten up because people thought or knew you were homosexual or not manly enough? (Choose one)

01 Never

02 Once

03 2 - 3 times

04 4 - 7 times

05 8 or more times

98 Refuse to Answer


NE2. In the past 12 months, how often have you been treated rudely or unfairly because people thought you were homosexual or not manly enough? (Choose one)

01 Never

02 Once

03 2 - 3 times

04 4 - 7 times

05 8 or more times

98 Refuse to Answer


NE3. In the past 12 months, how often have you been made fun of or called names because people thought you were homosexual or not manly enough? (Choose one)

01 Never

02 Once

03 2 - 3 times

04 4 - 7 times

05 8 or more times

98 Refuse to Answer


NE4. In the past 12 months, how often have you had to act more manly than usual in order to be accepted? (Choose one)

01 Never

02 Once

03 2 - 3 times

04 4 - 7 times

05 8 or more times

98 Refuse to Answer



NE5. In the past 12 months, how often have you felt uncomfortable in a crowd of straight (heterosexual) Blacks in Chicago because people thought you were homosexual or not manly enough? (Choose one)

01 Never

02 Once

03 2 - 3 times

04 4 - 7 times

05 8 or more times

98 Refuse to Answer


NE6. In the past 12 months, how often have you thought that you have been hit or beaten up because of your race or ethnicity? (Choose one)

01 Never

02 Once

03 2 - 3 times

04 4 - 7 times

05 8 or more times

98 Refuse to Answer


NE7. In the past 12 months, how often have you thought that you have been treated rudely or unfairly, or harassed, because of your race or ethnicity? (Choose one)

01 Never

02 Once

03 2 - 3 times

04 4 - 7 times

05 8 or more times

98 Refuse to Answer


NE8. In the past 12 months, how often have you felt uncomfortable in a crowd of white gay men because of your race or ethnicity? (Choose one)

01 Never

02 Once

03 2 - 3 times

04 4 - 7 times

05 8 or more times

98 Refuse to Answer


NE9. In the past 12 months, how often have you thought that you have had trouble finding a male lover or boyfriend because of your race or ethnicity? (Choose one)

01 Never

02 Once

03 2 - 3 times

04 4 - 7 times

05 8 or more times

98 Refuse to Answer



NE10. In the past 12 months, how often have you thought that men turned you down for sex because of your race or ethnicity? (Choose one)

01 Never

02 Once

03 2 - 3 times

04 4 - 7 times

05 8 or more times

98 Refuse to Answer

Adverse Childhood Event Scale


Module R: ACE - Adverse Childhood Event Scale


While you were growing up, during your first 18 years of life:


AC1. Did a parent or other adult in the household often or very often

Swear at you, insult you, put you down, or humiliate you?

or

Act in a way that made you afraid that you might be physically hurt?

01Yes

02 No

98. Refuse to Answer


ACE2. Did a parent or other adult in the household often or very often

Push, grab, slap, or throw something at you?

or

Ever hit you so hard that you had marks or were injured?

01Yes

02 No

98. Refuse to Answer


ACE3. Did an adult or person at least 5 years older than you ever

Touch or fondle you or have you touch their body in a sexual way against your will?

or

Attempt or actually have oral, anal, intercourse with you against your will?

01Yes

02 No

98. Refuse to Answer


ACE4. Did you often or very often feel that …

No one in your family loved you or thought you were important or special?

or

Your family didn’t look out for each other, feel close to each other, or support each other?

01Yes

02 No

98. Refuse to Answer



ACE5. Did you often feel that …

You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?

or

Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

01Yes

02 No

98. Refuse to Answer


ACE6. Were your parents ever separated or divorced?


01Yes

02 No

98. Refuse to Answer


ACE7. Was your mother or stepmother:

Often or very often pushed, grabbed, slapped, or had something thrown at her?

or

Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard?

or

Ever repeatedly hit at least a few minutes or threatened with a gun or knife?

01Yes

02 No

98. Refuse to Answer


ACE8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?

01Yes

02 No

98. Refuse to Answer


ACE9. Was a household member depressed or mentally ill, or did a household member attempt suicide?

01Yes

02 No

98. Refuse to Answer


ACE10. Did a household member go to prison?

01Yes

02 No

98. Refuse to Answer


Partner Violence Questionnaire (M/F versions)


Module S: PVQFP - Partner Violence Questionnaire (Female Partner)


If SA72 is equal to 2, Skip to PVQMP1.


Has any of the following ever happened with a girl friend or female partner?



PVQFP1. You pushed, shoved, kicked, hit or threw something at her?


  1. Yes

  2. No – SKIP to PVQFP2

98. Refuse to answer


PVQFP1a. If yes, has this happened within the past 90 days?


  1. Yes

  2. No

98. Refuse to answer


PVQFP2. You made fun of or humiliated her in front of others?


  1. Yes

  2. No – SKIP to PVQFP3

98. Refuse to answer


PVQFP2a. If yes, has this happened within the past 90 days?


  1. Yes

  2. No

98. Refuse to answer


PVQFP3. You forced her to have sex?


  1. Yes

  2. No – SKIP to PVQFP4

98. Refuse to answer


PVQFP3a. If yes, has this happened within the past 90 days?


  1. Yes

  2. No

98. Refuse to answer




PVQMP - Partner Violence Questionnaire (Male Partner)

Has any of the following ever happened with a male partner?


PVQMP1. He pushed, shoved, kicked, hit or threw something at you?


  1. Yes

  2. No – SKIP to PVQMP2

98. Refuse to answer


PVQMP1a. If yes, has this happened within the past 90 days?


  1. Yes

  2. No

98. Refuse to answer


PVQMP2. He made fun of or humiliated you in front of others?


  1. Yes

  2. No

98. Refuse to answer


PVQMP2a. If yes, has this happened within the past 90 days?


  1. Yes

  2. No

98. Refuse to answer


PVQMP3. He forced you to have sex?


  1. Yes

  2. No

98. Refuse to answer


PVQMP3a. If yes, has this happened within the past 90 days?


  1. Yes

  2. No

98. Refuse to answer


PVQMV4. You pushed, shoved, kicked, hit or threw something at him?


  1. Yes

  2. No – SKIP to PVQMV2

98. Refuse to answer



PVQMV4a. If yes, has this happened within the past 90 days?


  1. Yes

  2. No

98. Refuse to answer


PVQMV5. You made fun of or humiliated him in front of others?


  1. Yes

  2. No

98. Refuse to answer


PVQMV5a. If yes, has this happened within the past 90 days?


  1. Yes

  2. No

98. Refuse to answer


PVQMV6. You forced him to have sex?


  1. Yes

  2. No

98. Refuse to answer


PVQMV6a. If yes, has this happened within the past 90 days?


  1. Yes

  2. No

98. Refuse to answer


Everyday Discrimination – Sexual Orientation


Module T: ED-SO - Everyday Discrimination -Sexual Orientation


In your day-to-day life how often have any of the following things happened to you because of your sexual orientation?


EDSO1. You are treated with less courtesy than other people.


  1. Almost every day

  2. At least once a week

  3. A few times a month

  4. A few times a year

  5. Less than once a year

  6. Never

98. Refuse to Answer


EDSO2. You are treated with less respect than other people.


  1. Almost every day

  2. At least once a week

  3. A few times a month

  4. A few times a year

  5. Less than once a year

  6. Never

98. Refuse to Answer


EDSO3. You receive poorer service than other people at restaurants or stores.


  1. Almost every day

  2. At least once a week

  3. A few times a month

  4. A few times a year

  5. Less than once a year

  6. Never

98. Refuse to Answer


EDSO4. People act as if they think you are not smart.


  1. Almost every day

  2. At least once a week

  3. A few times a month

  4. A few times a year

  5. Less than once a year

  6. Never

98. Refuse to Answer


EDSO5. People act as if they are afraid of you.


  1. Almost every day

  2. At least once a week

  3. A few times a month

  4. A few times a year

  5. Less than once a year

  6. Never

98. Refuse to Answer


EDSO6. People act as if they think you are dishonest.


  1. Almost every day

  2. At least once a week

  3. A few times a month

  4. A few times a year

  5. Less than once a year

  6. Never

98. Refuse to Answer


EDSO7. People act as if they're better than you are.


  1. Almost every day

  2. At least once a week

  3. A few times a month

  4. A few times a year

  5. Less than once a year

  6. Never

98. Refuse to Answer


EDSO8. You are called names or insulted.


  1. Almost every day

  2. At least once a week

  3. A few times a month

  4. A few times a year

  5. Less than once a year

  6. Never

98. Refuse to Answer


EDSO9. You are threatened or harassed.

  1. Almost every day

  2. At least once a week

  3. A few times a month

  4. A few times a year

  5. Less than once a year

  6. Never

98. Refuse to Answer

Everyday Discrimination – Race


Module U: ED-R - Everyday Discrimination Race


In your day-to-day life how often have any of the following things happened to you because of your racial/ethnic identity?


EDR1. You are treated with less courtesy than other people.


  1. Almost every day

  2. At least once a week

  3. A few times a month

  4. A few times a year

  5. Less than once a year

  6. Never

98. Refuse to Answer


EDR2. You are treated with less respect than other people.


  1. Almost every day

  2. At least once a week

  3. A few times a month

  4. A few times a year

  5. Less than once a year

  6. Never

98. Refuse to Answer


EDR3. You receive poorer service than other people at restaurants or stores.


  1. Almost every day

  2. At least once a week

  3. A few times a month

  4. A few times a year

  5. Less than once a year

  6. Never

98. Refuse to Answer


EDR4. People act as if they think you are not smart.


  1. Almost every day

  2. At least once a week

  3. A few times a month

  4. A few times a year

  5. Less than once a year

  6. Never

98. Refuse to Answer


EDR5. People act as if they are afraid of you.


  1. Almost every day

  2. At least once a week

  3. A few times a month

  4. A few times a year

  5. Less than once a year

  6. Never

98. Refuse to Answer


EDR6. People act as if they think you are dishonest.

  1. Almost every day

  2. At least once a week

  3. A few times a month

  4. A few times a year

  5. Less than once a year

  6. Never

98. Refuse to Answer


EDR6. People act as if they're better than you are.


  1. Almost every day

  2. At least once a week

  3. A few times a month

  4. A few times a year

  5. Less than once a year

  6. Never

98. Refuse to Answer


EDR7. You are called names or insulted.


  1. Almost every day

  2. At least once a week

  3. A few times a month

  4. A few times a year

  5. Less than once a year

  6. Never

98. Refuse to Answer


EDR8. You are threatened or harassed.


  1. Almost every day

  2. At least once a week

  3. A few times a month

  4. A few times a year

  5. Less than once a year

  6. Never

98. Refuse to Answer

Black Identity (items from the Multidimensional Inventory of Black Identity/MIBI)


Module V: MIBI-Multidimensional Inventory of Black Identity (MIBI)


MIBI1. Overall, being Black has very little to do with how I feel about myself

1. Strongly Agree

2

3

4. Neutral

5

6

7. Strongly Agree

98. Refuse to Answer

MIBI2. I feel good about Black people.


1. Strongly Agree

2

3

4. Neutral

5

6

7. Strongly Agree

98. Refuse to Answer


MIBI3. In general, being Black is an important part of my self-image.


1. Strongly Agree

2

3

4. Neutral

5

6

7. Strongly Agree

98. Refuse to Answer

MIBI4. I am happy that I am Black.

1. Strongly Agree

2

3

4. Neutral

5

6

7. Strongly Agree

98. Refuse to Answer


MIBI5. 8. I feel that Blacks have made major accomplishments and advancements.


1. Strongly Agree

2

3

4. Neutral

5

6

7. Strongly Agree

98. Refuse to Answer

MIBI6. My destiny is tied to the destiny of other Black people.

1. Strongly Agree

2

3

4. Neutral

5

6

7. Strongly Agree

98. Refuse to Answer

MIBI7. I have a strong sense of belonging to Black people.


1. Strongly Agree

2

3

4. Neutral

5

6

7. Strongly Agree

98. Refuse to Answer

MIBI8. Being an individual is more important than identifying oneself as Black.

1. Strongly Agree

2

3

4. Neutral

5

6

7. Strongly Agree

98. Refuse to Answer


MIBI9. I have a strong attachment to other Black people.

1. Strongly Agree

2

3

4. Neutral

5

6

7. Strongly Agree

98. Refuse to Answer


Identification and Involvement with the Gay Community Scale


Module W: IGCS - Identification and Involvement with the Gay Community Scale (IGCS)


How much do you agree with the following statements?


IGCS1. It is very important to me that at least some of my friends are bisexual or homosexual.


1 Strongly disagree

2 Disagree

3 Do not agree or disagree

4 Agree

5 Strongly agree

98. Refuse to Answer


IGCS2. Identifying as gay makes me feel part of a community.


1 Strongly disagree

2 Disagree

3 Do not agree or disagree

4 Agree

5 Strongly agree

98. Refuse to Answer



IGCS3. Being attracted to men is important to my sense of who I am.


1 Strongly disagree

2 Disagree

3 Do not agree or disagree

4 Agree

5 Strongly agree

98. Refuse to Answer


IGCS4. I feel very distant from the gay community in general.


1 Strongly disagree

2 Disagree

3 Do not agree or disagree

4 Agree

5 Strongly agree

98. Refuse to Answer




IGCS5. I feel very distant from the black gay/homosexual community.

1 Strongly disagree

2 Disagree

3 Do not agree or disagree

4 Agree

5 Strongly agree

98. Refuse to Answer


For Questions 6-8, please think in terms of the last six months or so.


IGCS6. How often do you read a gay or lesbian oriented paper or magazine, such as the Advocate or other local gay/bisexual papers?


  1. Never

  2. Once a month or less

  3. Several times a month

  4. Several times a week or daily

98. Refuse to Answer


IGCS7. How often do you attend any gay or lesbian organizational activities, such as meetings, fund-raisers, political activities, etc.?


  1. Never

  2. Once a month or less

  3. Several times a month

  4. about once a week

  5. Several times a week or daily

98. Refuse to Answer


IGCS8. How often do you go to a gay bar?


1. Never

2. Once a month or less

3. Several times a month

4. about once a week

5. Several times a week or daily

98. Refuse to Answer


IGCS9. About how many gay/homosexual-identified men would you call personal friends (as opposed to casual acquaintances)?


1. None

2. One

3. Between 2 and 5

4. Between 6 and 10

5. More than 10

98. Refuse to Answer



IGCS10. How often do you attend any gay, lesbian, or bisexual organizational activities, such as meetings, fund raisers, political activities, etc. frequented by or geared toward black people?


1. Never

2. Once a month or less

3. Several times a month

4. about once a week

5. Several times a week or daily

98. Refuse to Answer


IGCS11. About how many black gay men, homosexual, lesbian, or bisexual women would you call personal friends (as opposed to casual acquaintances)?


1. One

2. Between 2 and 5

3. Between 6 and 10

4. More than 10

5.

98. Refuse to Answer


IGCS12. How often do you attend any social functions frequented by black people?


1. Never

2. Once a month or less

3. Several times a month

4. about once a week

5. Several times a week or daily

98. Refuse to Answer


IGCS13. How often do you attend any organizations activities, such as meetings, fund raisers, political activities, etc. frequented by black people (e.g., college alumni meetings, fraternity meetings, etc.)


1. Never

2. Once a month or less

3. Several times a month

4. about once a week

5. Several times a week or daily

98. Refuse to Answer



GCS14. About how many black men and women would you call personal friends (as opposed to casual acquaintances), regardless of sexual orientation?


1. None

2. One

3. Between 2 and 5

4. Between 6 and 10

5. More than 10

98. Refuse to Answer


Internalized Homophobia


Module X: IHS - Internalized Homophobia Scale


IH1. I often feel it is best to avoid personal or social involvement with other homosexual or bisexual men.


1. Strongly Disagree

2. Disagree

3. Agree

4. Strongly Agree

98. Refuse to Answer


IH2. I have tried to stop being attracted to men in general.


1. Strongly Disagree

2. Disagree

3. Agree

4. Strongly Agree

98. Refuse to Answer


IH3. If someone offered me the chance to be completely heterosexual, I would accept the chance.


1. Strongly Disagree

2. Disagree

3. Agree

4. Strongly Agree

98. Refuse to Answer


IH4. I wish I weren't sexually attracted to other men.


1. Strongly Disagree

2. Disagree

3. Agree

4. Strongly Agree

98. Refuse to Answer


IH5. I feel alienated from myself because of being gay/bisexual.


1. Strongly Disagree

2. Disagree

3. Agree

4. Strongly Agree

98. Refuse to Answer




IH6. I wish that I could be more sexually attracted to women.


1. Strongly Disagree

2. Disagree

3. Agree

4. Strongly Agree 98. Refuse to Answer


IH7. I feel that being homosexual/bisexual is a personal shortcoming for me.


1. Strongly Disagree

2. Disagree

3. Agree

4. Strongly Agree

98. Refuse to Answer


IH8. I would like to get professional help in order to change my sexual orientation from homosexual/bisexual to straight/heterosexual.


1. Strongly Disagree

2. Disagree

3. Agree

4. Strongly Agree

98. Refuse to Answer


IH9. I have tried to become more sexually attracted to women.


1. Strongly Disagree

2. Disagree

3. Agree

4. Strongly Agree

98. Refuse to Answer


Religion & Spirituality


Module Y:Religion and Spirituality


RS1. How often have you attended a place of worship (e.g., church, temple, mosque) during the past 6 months other than for a wedding or funeral? (Choose one)

1. Never – Skip to RS4

2. Once a week

3. 2-3 times a month

4 Once a month

5 Less than once a month

98 Refuse to Answer


RS2. Approximately how many people are Black at the place you worship?

1 All

2 More than half

3 About half

4 Less than half

5 None

98 Refuse to Answer


RS3. Of the people that you know at the place you worship, approximately how many are aware that you have sex with men? (Choose one)

1 All

2 More than half

3 About half

4 Less than half

5 None

98 Refuse to Answer


RS4. I am able to be open about my sexuality in my religious community with… (Choose one)

1. Everyone

2. More than half of those attending my religious community

3. About half of those attending my religious community

4. Less than half of those attending my religious community

5. None of those attending my religious community

98. Refuse to Answer







RS5. My religious beliefs make me feel bad about having sex with other men. (Choose one)


1. Always

2. More than half the time

3. About half the time

4. Less than half the time

5. None of the time

98. Refuse to Answer



RS6. I often have to choose my religious beliefs over my desire to be with a man. (Choose one)


1. Always

2. More than half the time

3. About half the time

4. Less than half the time

5. None of the time

98. Refuse to Answer


RS7. I always seek guidance from a higher power in times of need. (Choose one)

1. Always

2. Most times

3. About half the time

4. Less than half the time

5. Never – Skip to RS 9

98. Refuse to Answer


RS8. My spiritual connection with a higher power helps me cope with negative beliefs that other people have about homosexuality. (Choose one)


1. Always

2. More than half the time

3. About half the time

4. Less than half the time

5. None of the time

98. Refuse to Answer


RS9. My spiritual beliefs encourage me to do everything that I can to stay healthy. (Choose one)

1. Always

2. More than half the time

3. About half the time

4. Less than half the time

5. None of the time

98. Refuse to Answer

Cross-site

Module Z: Homegrown Cross site assessment items



Items for considerations across all 3 sites


I. Demographics

CS1. How many children do you have?

1._______

98 Refuse to Answer



CS2. Have you ever been told by a doctor or psychiatrist that you have a mental illness?

1. Yes

2. NO –Skip to CS7

98 Refuse to Answer



CS3. If yes, what was the diagnosis? (check all that apply)


1. Major Depression

2. Anxiety disorder

3. Bipolar disorder

4. Schizophrenia

5. Other specify

98. Refuse to Answer


CS4. If yes, have you ever been hospitalized because of your mental illness?

1. Yes

2. No

98 Refuse to Answer



CS5. If yes, has a doctor prescribed you medication to treat this mental illness?

1. Yes

2. No

98 Refuse to Answer





CS6. Are you taking the medication as the doctor prescribed?


1. Yes

2. No

98 Refuse to Answer



II. Outcome measures

Forgoing unsafe sex/ episodic abstinence


CS7. In the past 3 months, how many times did you NOT have anal or vaginal sex because you or your partner did not have a condom?



1.___________

98 Refuse to Answer




CS8. 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?

98 Refuse to Answer



CS9. Of those ____ times, how many times did you have vaginal or anal sex without a condom?

1. ___________

98 Refuse to Answer



Measuring sexual health/sexual well-being


General overall sexual satisfaction


CS10. 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

98 Refuse to Answer







CS11. During the past 3 months, how physically pleasurable was your sex life?


1 Not at all satisfying

2 Slightly satisfying

3 Moderately satisfying

4 Very satisfying

5 Extremely satisfying

98 Refuse to Answer




III. Other

Enema use


CS12. How often do you use enemas (insert a fluid into the anus to clean it out), in preparation for anal sex?

(4) Always, (3) Often, (2) Sometimes, (1) Rarely, (0) Never

98 Refuse to Answer



CS13. Do you expect your partner to use enemas (insert a fluid into the anus to clean it out) in preparation for anal sex?


(4) Always, (3) Often, (2) Sometimes, (1) Rarely, (0) Never

98 Refuse to Answer



How you met last partner


CS14. How did you first meet partner your most recent partner? (Choose one)

      1. Adult bookstore, sex club, bathhouse

      2. Gay bar /nightclub

      3. Church, political function

      4. Grocery store ****only in UNC

      5. Gym / health club / athletic activity

      6. Internet (hook up, dating or social networking site)

      7. Newspaper ads

      8. Non-gay bar, nightclub

      9. Private party

      10. Social club*** only in NC

      11. Public places including street, park, shopping mall, grocery store, l library, public transportation

      12. School

      13. Social organizations / volunteer service activities

      14. Through friend(s)

      15. Vacation / Business trip

      16. Work

      17. Some other­­ way, please specify:

98 Refuse to Answer




Internet and cell phone use

The next questions are about the Internet.


CS15. How do you usually access the Internet or go online? (Choose all that apply)

Cell phone, Computer at home, Computer at work, Computer in library or Internet café, Other specify, I don’t ever access the Internet

98 Refuse to Answer



CS16. During the last 3 months, how often did you go online to connect with or find gay Black men for social and personal connections other than sex?


1. Never

2. Very rarely

3. Monthly

4. Weekly

5. Daily

98 Refuse to Answer


CS17. During the last 3 months, how often did you go online to connect with or find male sex partners?

1. Never,

2. Very rarely,

3. Monthly,

4. Weekly,

5. Daily

98 Refuse to Answer



CS18. During the past 3 months, how often did you use apps on a cell phone or mobile device to find people for sex? Grindr and Jack’d are examples of apps.


1.Never

2. Very rarely

3. Monthly

4. Weekly

5. Daily

98 Refuse to Answer



If CS 18 is equal to Never, then skip.

1. What apps did you use, please specify _______________.

98 Refuse to Answer






iii

Version 15 2/2/2012

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Modified0000-00-00
File Created2021-01-30

© 2024 OMB.report | Privacy Policy