Form Adult Questionnair Adult Questionnair Adult Questionnaire

Minority Substance Abuse/HIV Prevention Initiative

HIV Adult Questionnaire_120321

Adult

OMB: 0930-0298

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Form Approved

OMB No.: 0930-0298

     Expiration Date:  XX/XX/XXXX







National Minority SA/HIV Prevention Initiative



Adult Questionnaire



TO BE COMPLETED BY THE LOCAL GRANT SITE DATA COLLECTOR


Last Name___________________, First Name___________________, M.I.______



Participant ID #: _____________________



















RESPONDENT OR PARTICIPANT: Before answering any of the questions, please make sure your name is correct. If incorrect, make the change in the box above. Do not write your name on any other page in this questionnaire. Thank you.



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National Minority SA/HIV Prevention Initiative


Adult Questionnaire



Funding for data collection supported by the
Center for Substance Abuse Prevention (CSAP)
Substance Abuse and Mental Health Services Administration (SAMHSA)
U.S. Department of Health and Human Services (HHS)


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These questions are part of a data collection effort about how to prevent substance abuse and HIV infection. The questions are being asked of hundreds of other individuals throughout the United States. The data findings will be used to help prevention initiatives learn more about how to keep people from using drugs and getting infected with HIV.


Completing this questionnaire is voluntary. If you do not want to answer any of the questions, you do not have to. If you decide not to participate in this survey, it will have no effect on your participation in direct service programs. However, your answers are very important to us. Please answer the questions honestly—based on what you really do, think, and feel. Your answers will not be told to anyone in your family or community. Do not write your name anywhere on this questionnaire.


We would like you to work fairly quickly so that you can finish. Please work quietly by yourself. If you have any questions or don’t understand something, let the data collector know.


We think you will find the questionnaire to be interesting and that you will like filling it out. Thank you very much for being an important part of this data collection effort!

Public Burden Statement: 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. The OMB control number for this project is 0930-0298. Public reporting burden for this collection of information is estimated to average 0.4 hours per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.


INSTRUCTIONS


1. Answer each question by marking one of the answer circles. Some questions allow you to mark more than one answer. If you don’t find an answer that fits exactly, choose the one that comes closest.


2. Mark your answers carefully so we can tell which answer circle you chose. Do not mark between the circles.


3. It is very important that you answer each question truthfully. Your responses will not be helpful unless you tell the truth.

___________________________________________________________________________________


MARKING YOUR ANSWERS

  • Use a No. 2 black lead pencil. EXAMPLES

  • Do not use an ink or ballpoint pen.

  • Make heavy dark marks that fill the circle completely. Correct Marks: Incorrect Marks:

  • EShape9 Shape7 Shape8 Shape10 Shape6 Shape5 Shape4 Shape3 rase cleanly any answer you wish to change.

  • Make no stray marks on this questionnaire.




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Record Management Section: To be Completed by Designated Staff

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Grant ID

S

P








Study Design Group (Select one)

Intervention Comparison


Participant ID








Date of Survey Administration


/


/


Month


Day


Year







Interview Type (Select one)

Baseline Exit Follow-up


Intervention Duration (Select one)

Single Session Intervention

Multiple Session Brief Intervention (less than 30 day duration)

Multiple Session Long Intervention (30 days or longer duration)


Intervention Name(s) (If the participant is receiving services for more than one intervention, please list each intervention below)

1.







2.








3.

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Section One: Facts About YouShape14


First, we’d like to ask some basic questions about you. Your answers will not be used to identify you in any way. Instead, your answers will help us understand how different groups (like men or women, or people of similar ages) feel about substance abuse and HIV prevention.


1. How would you describe yourself? (Gender)


Male

Female

Transgender

Male to female

Female to male


2. In what year were you born? (Enter all four digits of the year in the boxes below, and fill in corresponding circles)













1

2



0

1

2

3

4

5

6

7

8

9


0

1

2

3

4

5

6

7

8

9


0

1

2

3

4

5

6

7

8

9

3. In what month were you born?


January May September

February June October

March July November

April August December


4. Are you Hispanic or Latino?


Yes

No







5. What is your race? (Select one or more)


White

Black or African American

American Indian

Native Hawaiian or Other Pacific Islander

Asian

Alaska Native

Other


6. How would you describe yourself?

(Sexual orientation)


Straight or heterosexual

Bisexual

Gay or lesbian

Unsure


7. What is your primary spoken language?


English

Spanish

Asian (Chinese, Japanese, or other)

American Indian (Apache, Blackfoot, Navajo, or other)

Other


8. How long have you lived in the United States?


Less than a year

1 to 2 years

3 to 4 years

5 or more years

All my life


9. What is the highest level of education you have finished, whether or not you received a degree? (Mark the highest grade you have completed.)


1st grade College freshman

2nd grade College sophomore

3rd grade College junior

4th grade College completion

5th grade Some graduate school, but

6th grade no degree received

7th grade Master’s degree

8th grade Some professional school,

9th grade (such as medical or law

10th grade school) but no degree

11th grade received or doctoral

12th grade program

Doctorate or professional degree







10. If less than 12 years of education, do you have a GED (General Equivalency Diploma)?


Yes

No


11. Have you completed a technical or trade school program (such as beautician, cosmetology, business, appliance repair, computer etc.)?


Yes

No


12. Which of the following best describes you? (Mark the one that fits best)


Employed full time (35+ hours per week)

Employed part time

Unemployed (looking for work)

Unemployed (disabled)

Unemployed (volunteer work)

Unemployed (retired)

Unemployed (full-time student)

Unemployed (full-time homemaker)

Unemployed (other reason)


13. During the past 12 months, have you driven a vehicle while you were under the influence of alcohol?


Yes

No

Don’t know or can’t say


  1. Have you ever been in juvenile/adult detention, jail, or prison for more than 3 days?


Yes

No


15. If YES to question 14, how long has it been since you last got out of juvenile/adult detention, jail, or prison?


Never in juvenile/adult detention, jail, or prison for more than 3 days


Fewer than 30 days

Between 30 days and 1 year

Between 1 and 2 years

Between 2 and 3 years

Between 3 and 4 years

Between 4 and 5 years

More than 5 years


16. Have you ever served in the Armed Forces, in the Reserves, or the National Guard [select all that apply]?

No, (Skip to #17)

Yes, in the Armed Forces

Yes, in the Reserves

Yes, in the National Guard


16a. Are you currently on active duty in the Armed Forces, in the Reserves, or the National Guard [select all that apply]?


Yes, in the Armed Forces

Yes, in the Reserves

Yes, in the National Guard

No, separated or retired from Armed Forces, Reserves, or National Guard


16b. Have you even been deployed to a combat zone [select all that apply]?


Never deployed

Iraq or Afghanistan (e.g., Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn)

Persian Gulf (Operation Desert Shield or Desert Storm)

Vietnam/Southeast Asia

Korea

WWII

Deployed to a combat zone not listed above (e.g., Somalia, Bosnia, Kosovo)


17. Is anyone in your family or someone close to you on active duty in the Armed Forces, in the Reserves, or the National Guard, or separated or retired from Armed Forces, Reserves, or the National Guard?  

No, (Skip to #19)

Yes, 1 person

Yes, 2 people

Yes, 3 people

Yes, 4 people

Yes, 5 people

Yes, 6 or more people



18. If yes, answer the following questions for each person you marked in question 17 (up to six people).



Service Member #1

Service Member #2

Service Member #3

Service Member #4

Service Member #5

Service Member #6

Service Member’s relationship to you:

Mother

Father

Brother/Sister

Aunt/Uncle

Grandparent

Other

(specify) 

_______

_______

_______

_______

_______

_______

Has the Service Member experienced any of the following (select all that apply)?

18a. Deployed in support of combat operations
(e.g., Iraq or
Afghanistan)?

Yes
No

Don’t Know/Can’t Say

Yes
No

Don’t Know/Can’t Say

Yes
No

Don’t Know/Can’t Say

Yes
No

Don’t Know/Can’t Say

Yes
No

Don’t Know/Can’t Say

Yes
No

Don’t Know/Can’t Say

18b. Was physically injured during combat operations?

Yes
No

Don’t Know/Can’t Say

Yes
No

Don’t Know/Can’t Say

Yes
No

Don’t Know/Can’t Say

Yes
No

Don’t Know/Can’t Say

Yes
No

Don’t Know/Can’t Say

Yes
No

Don’t Know/Can’t Say

18c. Developed combat stress symptoms/ difficulties adjusting following deployment, including PTSD, depression, or suicidal thoughts?

Yes
No

Don’t Know/Can’t Say

Yes
No

Don’t Know/Can’t Say

Yes
No

Don’t Know/Can’t Say

Yes
No

Don’t Know/Can’t Say

Yes
No

Don’t Know/Can’t Say

Yes
No

Don’t Know/Can’t Say

18d. Died or was killed?

Yes
No

Don’t Know/Can’t Say

Yes
No

Don’t Know/Can’t Say

Yes
No

Don’t Know/Can’t Say

Yes
No

Don’t Know/Can’t Say

Yes
No

Don’t Know/Can’t Say

Yes
No

Don’t Know/Can’t Say



End of Section One




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Section Two: Attitudes & KnowledgeShape16



Next, we’d like to ask you how you feel about substance use and sexual behavior, as well as what you know about HIV/AIDS. Again, your answers are private and will not be used to identify you.




The next few questions ask about HOW MUCH you think people RISK HARMING themselves physically or in other ways by using alcohol, tobacco, and drugs.


19. How much do people risk harming themselves physically or in other ways when they smoke one or more packs of cigarettes per day?


No risk

Slight risk

Moderate risk

Great risk

Don’t know or can’t say


20. How much do people risk harming themselves physically or in other ways when they smoke marijuana once or twice a week?


No risk

Slight risk

Moderate risk

Great risk

Don’t know or can’t say


21. How much do people risk harming themselves physically or in other ways when they have five or more drinks of an alcoholic beverage once or twice a week?


No risk

Slight risk

Moderate risk

Great risk

Don’t know or can’t say
















The next questions are about your beliefs and attitudes toward SEX.


Some of the questions ask about having sex. By sex or sexual activity, we mean a situation where two partners get sexually excited or aroused (turned on) by touching each other’s genitals (penis or vagina) or anus (butt) with their own genitals, hands, or mouth.


When a male inserts his penis into his female partner’s vagina, the partners are considered to be having vaginal sex.


When one partner’s mouth is in contact with the other partner’s genitals (penis or vagina) or anus during sex, the partners are considered to be having oral sex.


When a male’s penis is inserted into his male or female partner’s anus, the partners are considered to be having anal sex.


Some questions ask about sexual partners. A sexual partner is someone with whom you have sex, that is, engage in sexual activity.


Some questions refer to protected sex and unprotected sex. Protected sex is when a latex or polyurethane condom (rubber) is used to cover the penis; a female condom is used to cover the vagina; or a dental dam is used to cover the anus. By unprotected sex, we mean vaginal, oral, or anal sex without a barrier such as a condom or dental dam.


How much do you think people risk harming themselves physically:


22. If they have oral sex without a condom or dental dam?

No risk

Slight risk

Moderate risk

Great risk





23. If they have vaginal sex without a condom?

No risk

Slight risk

Moderate risk

Great risk


24. If they have anal sex without a condom?

No risk

Slight risk

Moderate risk

Great risk


25. If they have sex under the influence of alcohol?

No risk

Slight risk

Moderate risk

Great risk


26. If they have sex while high on drugs?

No risk

Slight risk

Moderate risk

Great risk


27. If they share nonsanitized needles or works when using drugs? (“Works” refer to supplies used for injecting drugs)

No risk

Slight risk

Moderate risk

Great risk


The next questions ask more about your attitudes and beliefs about sex.


In your relationship with your PRIMARY (MAIN) partner, how confident are you that you could:


28. Refuse to have sex with your partner because you weren’t in the mood?


Not at all

A little

Somewhat

Very much


29. Ask your partner to wait while you got a condom or dental dam?


Not at all

A little

Somewhat

Very much

30. Tell your partner how to treat you sexually?


Not at all

A little

Somewhat

Very much


31. Refuse to engage in sexual practices you didn’t like?


Not at all

A little

Somewhat

Very much


32. Ask your partner to use a condom or dental dam?


Not at all

A little

Somewhat

Very much


33. Refuse to have sex because your partner did not want to use a condom or dental dam?


Not at all

A little

Somewhat

Very much


The next set of questions ask how likely you are to do certain behaviors in the future.


In the next 6 months, how likely are you...


34. To drink five or more alcoholic drinks in one sitting?


Not at all likely

A little likely

Somewhat likely

Very likely


35. To use any illegal drugs (including prescription drugs) to get high?


Not at all likely

A little likely

Somewhat likely

Very likely


36. To use injection drugs without a doctor’s orders, just to feel good or to get high?


Not at all likely

A little likely

Somewhat likely

Very likely

37. To use clean needles when injecting drugs?


I do not use injected drugs


Not at all likely

A little likely

Somewhat likely

Very likely


38. To practice safe sex?


  • Not intending to have sex during the next 6 months


  • Not at all likely

  • A little likely

  • Somewhat likely

  • Very likely


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HIV/AIDS – What You Know

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Please indicate whether you think each of the following statements about HIV/AIDS is true or false, or if you don’t know.

39. Only people who look sick can spread the HIV/AIDS virus.

True

False

Don’t know


40. Only people who have sexual intercourse with gay (homosexual) people get HIV/AIDS.

True

False

Don’t know


41. Birth control pills protect women from getting the HIV/AIDS virus.

True

False

Don’t know


42. There are drugs available to treat HIV that can lengthen the life of a person infected with the virus.

True

False

Don’t know


43. There is no cure for AIDS.

True

False

Don’t know


44. Young people under age 18 need their parents’ permission to get an HIV test.

True

False

Don’t know



The next questions ask about health care services.



45. Would you know where to go in your neighborhood to see a health care professional regarding HIV/AIDS or other sexually transmitted health issues?

Yes

No


46. Would you know where to go in your neighborhood to see a health care professional regarding a drug or alcohol problem?

Yes

No


47. Have you ever been tested for the HIV virus that causes AIDS?

Yes

No


48. If YES to Question 47, what type of HIV test was it?


Never tested for HIV/AIDS

Oral (Mouth) test (OraSure/OraQuick Rapid Saliva Test or other)

Urine test

Blood test in a clinic or doctor’s office (Western Blot or other)

More than one test conducted in a clinic or doctor’s office

Home test kit

Don’t know


49. If YES to question 47, did you receive or go back to get your results?

Never tested for HIV/AIDS

Yes

No



The following questions ask about your relationships.



Thinking about all the people you know…


50. Are there any people you could go to when you want to talk about things having to do with your own health?

Yes, there are people I can talk with

No, there is no one I can talk with


51. Are there any people you could talk with about personal issues having to do with sex?


Yes, there are people I can talk with

No, there is no one I can talk with


52. Are there any people you could talk with about personal issues having to do with alcohol or drug use?


Yes, there are people I can talk with

No, there is no one I can talk with


53. Are there certain people you could go to if you need to talk about other personal matters that you wouldn’t tell just anyone?


Yes, there are people I can talk with

No, there is no one I can talk with




The next few questions ask about your religious or spiritual beliefs and how they may affect your daily life.



54. In general, how important are religious or spiritual beliefs in your day-to-day life?

Not at all important

Not too important

Fairly important

Very important


55. When you have problems or difficulties with your school (education), work, family, friends, or personal life, how often do you seek spiritual guidance and support?

Never

Rarely

Sometimes

Often

Almost always







56. How spiritual or religious would you say you are?


Not spiritual or religious at all

Not too spiritual or religious

Fairly spiritual or religious

Very spiritual or religious


























End of Section Two


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Section Three: Behavior & RelationshipsShape21



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Cigarettes, Alcohol and Drugs

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The next two questions are about CIGARETTES and OTHER TOBACCO PRODUCTS.


Think back over the past 30 days and record on how many days, if any, you used cigarettes and/or other tobacco products.


57. During the past 30 days, on how many days did you smoke part or all of a cigarette? (Includes menthol and regular cigarettes and loose tobacco rolled into cigarettes)


0 days 12 days 24 days

1 day 13 days 25 days

2 days 14 days 26 days

3 days 15 days 27 days

4 days 16 days 28 days

5 days 17 days 29 days

6 days 18 days 30 days

7 days 19 days Don’t know

8 days 20 days or can’t say

9 days 21 days

10 days 22 days

11 days 23 days

58. During the past 30 days, on how many days did you use other tobacco products? (Includes any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe)


0 days 12 days 24 days

1 day 13 days 25 days

2 days 14 days 26 days

3 days 15 days 27 days

4 days 16 days 28 days

5 days 17 days 29 days

6 days 18 days 30 days

7 days 19 days Don’t know

8 days 20 days or can’t say

9 days 21 days

10 days 22 days

11 days 23 days






The next two questions are about ALCOHOL.

By alcohol, we mean BEER, WINE, WINE COOLERS, MALT BEVERAGES or HARD LIQUOR.


Different groups of people in the United States may use alcohol for religious reasons. For example, some churches serve wine during a church service. If you drink wine at church or for some other religious reason, do not count these times in your answers to the questions below.


Think back over the past 30 days and record on how many days, if any, you consumed alcohol.

59. During the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage?


0 days 12 days 24 days

1 day 13 days 25 days

2 days 14 days 26 days

3 days 15 days 27 days

4 days 16 days 28 days

5 days 17 days 29 days

6 days 18 days 30 days

7 days 19 days Don’t know

8 days 20 days or can’t say

9 days 21 days

10 days 22 days

11 days 23 days


60. During the past 30 days, on how many days did you have 4 or more drinks on the same occasion? [By 'occasion,' we mean at the same time or within a couple of hours of each other].


0 days 12 days 24 days

1 day 13 days 25 days

2 days 14 days 26 days

3 days 15 days 27 days

4 days 16 days 28 days

5 days 17 days 29 days

6 days 18 days 30 days

7 days 19 days Don’t know

8 days 20 days or can’t say

9 days 21 days

10 days 22 days

11 days 23 days





61. During the past 30 days, on how many days did you have 5 or more drinks on the same occasion? [By 'occasion,' we mean at the same time or within a couple of hours of each other].


0 days 12 days 24 days

1 day 13 days 25 days

2 days 14 days 26 days

3 days 15 days 27 days

4 days 16 days 28 days

5 days 17 days 29 days

6 days 18 days 30 days

7 days 19 days Don’t know

8 days 20 days or can’t say

9 days 21 days

10 days 22 days

11 days 23 days

62. During the past 30 days, on how many days have you been drunk or very high from drinking alcoholic beverages?


0 days 12 days 24 days

1 day 13 days 25 days

2 days 14 days 26 days

3 days 15 days 27 days

4 days 16 days 28 days

5 days 17 days 29 days

6 days 18 days 30 days

7 days 19 days Don’t know

8 days 20 days or can’t say

9 days 21 days

10 days 22 days

11 days 23 days



The next question is about MARIJUANA or HASHISH. Marijuana is sometimes called weed, blunt, hydro, grass, or pot. Hashish is sometimes called hash or hash oil.


Think back over the past 30 days and record on how many days, if any, you used marijuana or hashish.


63. During the past 30 days, on how many days did you use marijuana or hashish?


0 days 12 days 24 days

1 day 13 days 25 days

2 days 14 days 26 days

3 days 15 days 27 days

4 days 16 days 28 days

5 days 17 days 29 days

6 days 18 days 30 days

7 days 19 days Don’t know

8 days 20 days or can’t say

9 days 21 days

10 days 22 days

11 days 23 days



The next question is about OTHER ILLEGAL DRUGS, excluding marijuana or hashish.


These include substances like inhalants or sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, or shoe polish (used to feel good or get high), heroin, crack, or cocaine, methamphetamine, hallucinogens (drugs that cause people to see or experience things that are not real) such as LSD (sometimes called acid), Ecstasy (MDMA), PCP, peyote (sometimes called angel dust), and prescription drugs used without a doctor’s orders, just to feel good or to get high.


Think back over the past 30 days and record on how many days, if any, you used other illegal drugs.


64. During the past 30 days, on how many days did you use any other illegal drug?


0 days 12 days 24 days

1 day 13 days 25 days

2 days 14 days 26 days

3 days 15 days 27 days

4 days 16 days 28 days

5 days 17 days 29 days

6 days 18 days 30 days

7 days 19 days Don’t know

8 days 20 days or can’t say

9 days 21 days

10 days 22 days

11 days 23 days




Now we would like to ask about your use of several specific drugs during the past 30 days.


65. During the past 30 days, on how many days did you use cocaine or crack?


0 days 12 days 24 days

1 day 13 days 25 days

2 days 14 days 26 days

3 days 15 days 27 days

4 days 16 days 28 days

5 days 17 days 29 days

6 days 18 days 30 days

7 days 19 days Don’t know

8 days 20 days or can’t say

9 days 21 days

10 days 22 days

11 days 23 days







66. During the past 30 days, on how many days did you use methamphetamine? (Also called meth, crystal meth, crank, go, and speed)


0 days 12 days 24 days

1 day 13 days 25 days

2 days 14 days 26 days

3 days 15 days 27 days

4 days 16 days 28 days

5 days 17 days 29 days

6 days 18 days 30 days

7 days 19 days Don’t know

8 days 20 days or can’t say

9 days 21 days

10 days 22 days

11 days 23 days


67. During the past 30 days, on how many days have you used prescription drugs without a doctor’s orders, in order to feel good or to get high?


0 days 12 days 24 days

1 day 13 days 25 days

2 days 14 days 26 days

3 days 15 days 27 days

4 days 16 days 28 days

5 days 17 days 29 days

6 days 18 days 30 days

7 days 19 days Don’t know

8 days 20 days or can’t say

9 days 21 days

10 days 22 days

11 days 23 days


68. During the past 30 days, on how many days have you injected any drugs? (Count only injections without a doctor’s orders you used to feel good or to get high.)


0 days 12 days 24 days

1 day 13 days 25 days

2 days 14 days 26 days

3 days 15 days 27 days

4 days 16 days 28 days

5 days 17 days 29 days

6 days 18 days 30 days

7 days 19 days Don’t know

8 days 20 days or can’t say

9 days 21 days

10 days 22 days

11 days 23 days










69. During the past 30 days, how stressful have things been for you because of your use of alcohol or drugs?


I have not used alcohol or drugs in the past 30 days


Not at all

Somewhat

Considerably

Extremely


70. During the past 30 days, has your use of alcohol or drugs caused you to have emotional problems?


I have not used alcohol or drugs in the past 30 days


Not at all

Somewhat

Considerably

Extremely



The next few questions ask about the FIRST TIME you used a substance.


Think back whether you have EVER used any substances. If so, what was your age the FIRST TIME you used the following substances.


71. How old were you the first time you smoked part or all of a cigarette? (Includes menthol and regular cigarettes and loose tobacco rolled into cigarettes)

I have never smoked part or all of a
cigarette


5 years old or younger 20 years old

6 years old 21 years old

7 years old 22 years old

8 years old 23 years old

9 years old 24 years old

10 years old 25 years old

11 years old 26 years old

12 years old 27 years old

13 years old 28 years old

14 years old 29 years old

15 years old 30 years old

16 years old Over 30

17 years old years old

18 years old Don’t know

19 years old or can’t say






72. How old were you the first time you used any other tobacco product? (Includes any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe)


I have never used any other tobacco products


5 years old or younger 20 years old

6 years old 21 years old

7 years old 22 years old

8 years old 23 years old

9 years old 24 years old

10 years old 25 years old

11 years old 26 years old

12 years old 27 years old

13 years old 28 years old

14 years old 29 years old

15 years old 30 years old

16 years old Over 30

17 years old years old

18 years old Don’t know

19 years old or can’t say


73. How old were you the first time you had a drink of an alcoholic beverage? (Includes beer, wine, wine coolers, malt beverages, and liquor) DO NOT include any time when you only had a sip or two from a drink.


I have never had a drink of an alcoholic beverage


5 years old or younger 20 years old

6 years old 21 years old

7 years old 22 years old

8 years old 23 years old

9 years old 24 years old

10 years old 25 years old

11 years old 26 years old

12 years old 27 years old

13 years old 28 years old

14 years old 29 years old

15 years old 30 years old

16 years old Over 30

17 years old years old

18 years old Don’t know

19 years old or can’t say














74. How old were you the first time you used marijuana or hashish? (Also known as grass, pot, hash, or hash oil)

I have never used marijuana or hashish


5 years old or younger 20 years old

6 years old 21 years old

7 years old 22 years old

8 years old 23 years old

9 years old 24 years old

10 years old 25 years old

11 years old 26 years old

12 years old 27 years old

13 years old 28 years old

14 years old 29 years old

15 years old 30 years old

16 years old Over 30

17 years old years old

18 years old Don’t know

19 years old or can’t say


75. How old were you the first time you used any other illegal drug?


I have never used any other illegal drugs


5 years old or younger 20 years old

6 years old 21 years old

7 years old 22 years old

8 years old 23 years old

9 years old 24 years old

10 years old 25 years old

11 years old 26 years old

12 years old 27 years old

13 years old 28 years old

14 years old 29 years old

15 years old 30 years old

16 years old Over 30

17 years old years old

18 years old Don’t know

19 years old or can’t say












Shape24

Sexual Behavior

Shape25


Now we’d like to ask you about your experience with sex. If you cannot remember what we mean by sex, please refer to the definitions on page 4. Remember, your answers are private.


76. Have you ever had sex (either vaginal, oral, or anal)?


Yes

No


77. Have you had oral sex in the past 30 days?

Yes

No


78. The last time you had oral sex, was it protected or unprotected?


I have never had oral sex


Protected

Unprotected


79. Have you had vaginal sex in the past 30 days?

Yes

No


80. The last time you had vaginal sex, was it protected or unprotected?


I have never had vaginal sex


Protected

Unprotected


81. Have you had anal sex in the past 30 days?

Yes

No


82. The last time you had anal sex, was it protected or unprotected?


I have never had anal sex


Protected

Unprotected








The next set of questions asks more specifically about your sexual behavior. Some questions refer to the past 3 months and others to your experience ever.


83. In the past 3 months, have you had sex with any men?


Yes

No


84. Are you a woman who has sex with men?


Yes

No


85. Are you a man who has sex with men?


Yes

No



86. In the past 3 months, have you had sex with any women?


Yes

No


87. Are you a man who has sex with women?


Yes

No


88. Are you a woman who has sex with women?


Yes

No


89. During the past 3 months, how many sexual partners have you had?


None 6 people

1 person 7 people

2 people 8 people

3 people 9 people

4 people 10 people or more

5 people


90. Have you ever had unprotected sex (vaginal, anal, or oral) with someone in exchange for money, drugs, or shelter?


Yes

No






91. In the past 3 months, have you had unprotected sex (vaginal, anal, or oral) with someone in exchange for money, drugs, or shelter?


Yes

No


92. Have you ever had unprotected sex (vaginal, anal, or oral) with a partner you know had, or suspected of having a sexually transmitted disease (STD)?


Yes

No


93. In the past 3 months, have you had unprotected sex (vaginal, anal, or oral) with a partner you know had, or suspected of having a sexually transmitted disease (STD)?


Yes

No


94. Have you ever had unprotected sex (vaginal, anal, or oral) with a partner you know had, or suspected of having HIV/AIDS?


Yes

No


95. In the past 3 months, have you had unprotected sex (vaginal, anal, or oral) with a partner you know had, or suspected of having HIV/AIDS?


Yes

No



96. Have you ever had unprotected sex (vaginal, anal, or oral) with someone whom you knew was, or suspected of being an injected drug user?


Yes

No


97. In the past 3 months, have you had unprotected sex (vaginal, anal, or oral) with someone whom you knew was, or suspected of being an injected drug user?


Yes

No







98. Have you ever had sex while you were under the influence of drugs or alcohol?


Yes

No


99. In the past 3 months, have you had sex while you were under the influence of drugs or alcohol?


Yes

No


The next few questions ask about abuse you might have experienced.


In the past 3 months, how often has anyone with whom you had an intimate relation, sexual or not…

100. Emotionally abused you (swore at you, called you negative names, kept you from seeing family or friends)?


Never

Rarely

Sometimes

Often

Very often


101. Physically abused you (slapped, beat, kicked, or choked you; threatened you with a knife or a gun)?


Never

Rarely

Sometimes

Often

Very often


102. Sexually abused you (forced you to have sex, physically hurt the sexual parts of your body)?


Never

Rarely

Sometimes

Often

Very often


103. Forced you to use drugs or alcohol?


Never

Rarely

Sometimes

Often

Very often






Shape26

Family, Relationships and Work

Shape27


104. Describe your current relationship status.


Single (never married)

Informally married or living with a permanent partner

Legally married

Separated

Divorced or broken up from an informal marriage

Widowed


105. With whom do you live?
(Mark all that apply)


Alone

With my mother

With my father

With my brother(s) and/or sister(s)

With my grandparent(s)

With other relatives or guardian

With my spouse or significant other

With my child or my children

With roommates

Other


106. Describe where you live.


In my own home or apartment

In a relative’s home

In a group home

In a foster home

Homeless or in a shelter

Other


107. At what age did you have your first child?


No children

9 to 13 years old

14 to 18 years old

19 to 25 years old

26 to 34 years old

35 years old or older


108. How many children under the age of 18 are living with you?


0

1 to 2

3 to 4

5 to 6

More than 6


109. If you have children, during the past 12 months, how many times have you talked with your children about the dangers or problems associated with the use of tobacco, alcohol, or drugs?


I don’t have any children


0 times

1 to 2 times

A few times

Many times

Don’t know or can’t say


110. Think about the household members that live with you right now. About how much income have you and/or your family members made in the last year before taxes? (Include child support and/or cash payments from the government, for example, welfare [TANF], SSI, or unemployment compensation)


$0–$10,000

$10,001–$20,000

$20,001–$30,000

$30,001–$40,000

$40,001–$50,000

$50,001–$60,000

More than $60,000



111. Do you have health care or medical insurance?

Yes

No


112. Would you be more or less likely to want to work for an employer that tests its employees for drug or alcohol use on a random basis? Would you say more likely, less likely, or would it make no difference to you? (Mark one)


More likely

Less likely

Would make no difference

Don’t know or can’t say














The next set of questions asks about your family’s relationships.


113. I’m available when others in my family want to talk to me.


I don’t have any family

Not true

Sometimes true

Usually true

Always true


114. I listen to what other family members have to say, even when I disagree.


I don’t have any family

Not true

Sometimes true

Usually true

Always true


115. Members of my family ask each other for help.


I don’t have any family

Not true

Sometimes true

Usually true

Always true


116. Members of my family like to spend free time with each other.


I don’t have any family

Not true

Sometimes true

Usually true

Always true

117. Members of my family feel very close to each other.


I don’t have any family

Not true

Sometimes true

Usually true

Always true









118. We can easily think of things to do together as a family.


I don’t have any family

Not true

Sometimes true

Usually true

Always true



The next two questions ask about programs or classes you may have attended recently.


119. In the past 30 days, have you been in any classes or programs where they talked about prevention of drug or alcohol abuse?

Yes

No


120. In the past 30 days, have you been in any classes or programs where they talked about preventing HIV/AIDS?

Yes

No



The last two questions ask about your experience with this survey.


121. How comfortable was it for you to answer the questions in this survey?


Very comfortable

Somewhat comfortable

Somewhat uncomfortable

Very uncomfortable


122. How truthful were you when answering the questions?


Very truthful

Somewhat truthful

Somewhat untruthful

Very untruthful






YOU ARE DONE!

Thank you for your help!


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleHIV Cohort 6 Adult Baseline Questionnaire
AuthorCalverton
File Modified0000-00-00
File Created2021-01-30

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