GYT: Get Yourself Tested Instrument

Evaluation of the Get Yourself Tested (GYT) Campaign

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GYT: Get Yourself Tested

OMB: 0920-0957

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Attachment 6:

GYT: Get Yourself Tested

Survey instrument

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including 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 Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN:PRA (0920-####)

Knowledge, Attitudes and Preferences

For each topic below, check the box that is closest to your opinion:

I think this topic is…	A major concern for people my age	A minor concern for people my age	Not a concern at all for people my age	Don’t know
HIV/AIDS
Genital Herpes
Other STDs (not HIV) [define like Chlamydia, gonorrhea, syphilis, trichomoniasis]
Unintended or Unplanned Pregnancy

For each topic below, check the box that is closest to your opinion

What are the chances that this will happen?	Almost impossible	A small chance	About a 50-50 chance	Greater than 50% chance
I become infected with HIV/AIDS
I become infected with Genital Herpes
I become infected with other STDs (not HIV) [define like Chlamydia, gonorrhea, syphilis, trichomoniasis]
I get pregnant (female) or get a girl pregnant (male)

For each topic below, check the box that is closest to your opinion.

If I found out that I had the following conditions, it would be…	A major problem	A minor problem	Not a problem at all	I don’t know what this is
HIV/AIDS
Genital Herpes
Other STDs (not HIV) [define like Chlamydia, gonorrhea, syphilis, trichomoniasis]
Pregnancy

Think about the information you’ve learned about sex and sexual health from all the different people or places in your life. Check all the sources of information that helped you learn about….

	Parents	Other trusted adult	Brother or sister	Boyfriend or Girlfriend	Friends	Doctor or other health care provider	Online experts or question-answer websites	Searching the Internet	Social media like Facebook, Twitter etc	Television or radio	Magazines or other printed material	Classes or programs at school	Religious institution	No source of info
Whether/when to have sex
What to expect in a sexual or intimate relationship
Mechanics of sex
Morals and values about sex
Emotions about sex
Pregnancy
Birth control
Forced sex or rape
HIV
STDs other than HIV
How to prevent HIV/STDs during sex

Thinking about the places where you might learn about sex and sexual health, would you say these information sources are…(check all that apply)

	Comfortable for me	Accurate	Trustworthy	Confidential	Nonjudgmental	Easily accessed or approachable	Not applicable to me (I’ve never looked for sex-related info from this source)
Parents or Guardians
Other trusted adult
Brother or sister
Boyfriend or Girlfriend
Friends
Doctors or health care providers
Searching the Internet
Social media like Facebook, Twitter or text message service
Television or radio
Magazines, newspapers or other printed material
Classes or programs at school
Religious institution

Now, thinking about all the different STDs, including HIV, about how many sexually active young people in this country do you think will get an STD by age 25?
1. 1 in 2000
2. 1 in 200
3. 1 in 20
4. 1 in 2
5. Don’t know

Which items below are true and which are false?
1. You can get an STD from a person who has no signs or symptoms of an STD.
2. You can get an STD even if you only have sex with one person.
3. You can get tested for all STDs with one test.
4. Certain STDs can cause some kinds of cancer.
5. All STDs can be completely cured. (Rollover definition: “cured” means that the disease is completely gone from your body.)
6. Using condoms reduces the risk of STDs, including HIV.
7. If you have an STD, your risk of getting HIV (if exposed to a partner with HIV) is higher.
8. Some STDs can lead to infertility (problems getting pregnant), if left untreated.
9. Women automatically get tested for all STDs when they get a Pap test or Pap smear.
10. You can tell if someone has an STD by looking.
11. All STDs can be treated. (Rollover definition: “treated” means that the disease is still in your body, but the symptoms are reduced or the symptoms disappear)

Below is a list of reactions or thoughts you might have if your boyfriend or girlfriend asked that you get tested for an STD. Check the boxes that might describe your thoughts if your boyfriend or girlfriend suggested that you get tested (check all that apply).
1. S/He cares about me
2. S/He thinks I’m having sex with someone else
3. S/he is probably having sex with someone else
4. It is smart to make sure we are both healthy
5. S/He thinks I’m dirty
6. S/He does not trust me
7. S/He is being careful
8. S/He is being responsible
9. None of the above

Please tell us what you think about people who have STDs (check all that apply). “People who have STDs…”

Should be avoided
may not even know it
are dirty
are no different than those who don’t have STDs
have obviously slept with a lot of people
may just have had bad luck
have poor morals
should be given the benefit of the doubt
should be ashamed of themselves
can still have healthy, normal relationships
don’t take care of themselves

hang with the wrong crowd
should not be afraid to tell their close friends

should be able to tell their friends without feeling judged
none of the above

Please tell us what you think about people who get tested for STDs (check all that apply). “People who get tested for STDs…”

are taking care of their sexual health
must have “slipped up”
are probably cheating on their boy/girlfriend
are responsible sex partners/lovers
must have slept with a lot of people
should do it regularly, as part of their routine health care
must be dirty
none of the above

Please tell us how you would feel if you got diagnosed with an STD (check all that apply). “If I was diagnosed with an STD (other than HIV), I would….”

be devastated
be surprised
keep in mind that STDs are really common
feel alone
look to a close friend/family member/partner for support
feel ashamed
feel confident that I could do what I needed to do to treat it
be afraid of what this will mean for my reputation
know that this doesn’t change or define who I am
hide it, even from my closest friends and family members
be able to talk about it with a close friend or family member
[none of the above]

In your opinion, how effective are condoms (if used from start-to-finish when you have sex) at each of the following?

	Condoms are very effective	Condoms are somewhat effective	Condoms are not at all effective	I don’t know how effective condoms are
Preventing pregnancy
Preventing HIV
Preventing bacterial STDs like chlamydia or gonorrhea
Preventing viral STDs like genital herpes or human papillomavirus (HPV)

Sexual Behavior and Experience

There are many different kinds of behaviors that could be considered sexual. Thinking back on your whole life, check which of these you have done or had:
1. Kissing
2. Touching another person sexually (define: touching breasts, vagina, penis)
3. Giving oral sex (define: putting your mouth on someone else’s penis or vagina)
4. Receiving oral sex (define: someone else’s mouth on your penis or vagina)
5. Vaginal intercourse (define: a penis inserted into a vagina)
6. Anal intercourse (define: a penis in inserted into an anus)

(If any of 13e-f is checked indicating intercourse): How old were you when you had sexual intercourse (rollover definition: vaginal or anal sex) for the first time? ______

(If any of 13e-f is checked indicating intercourse): With how many people have you had sexual intercourse(rollover definition: vaginal or anal sex) in your life? _____

There are many types of sexual relationships. Think back over all the relationships you have had. Check all that you have had:

(for all options below: define sex: oral, vag, anal)

Sex with a male
Sex with a female
Anonymous sex (rollover definition: sex with someone whose name you didn’t know)
Sex with someone you had just met
Sex with someone you didn’t know very well
Sex with a friend(define: having sex with friends, but it isn’t considered dating)
Sex with boyfriend or girlfriend (define: a person you are “dating”)
Sex with someone with whom you are in a serious, committed relationship
Never had sex with another person

Are you involved in one of these sexual situations now? (Check all that apply)

Recent Sex with someone you just met or don’t know very well
Sex with a friends (define: having sex with friends, but it isn’t considered dating)
Sex with a boyfriend or girlfriend (define: a person you are “dating”)
Sex with someone with whom you are in a serious, committed relationship
Same-sex sexual relationship
Not in a sexual relationship

Different people have different opinions about what they value in relationships. Which of the following possible aspects of relationships are important to you, either in a relationship you have or would like to have?

	Very important to me	Important to me	Not very important to me	Not at all important to me

Emotional aspects How your relationship helps you feel good about or happy with yourself and your life
Social aspects How your relationship helps you feel connected to others in your world
Pleasure The overall level of enjoyment you get from the relationship
Spiritual aspects How your relationship adds to a deeper sense of meaning and purpose in life
Mutual aspects How your relationship benefits everyone in it
Mental How your relationship satisfies you on an intellectual level
Physical aspects How your relationship meets your needs for sexual intimacy; (e.g., kissing, sex)

Do you and/or your partner use any of the following as part of your sexual relationships?
1. Birth control pills
2. Other birth control like depo shots, implants, the patch, the ring, IUD, diaphragm or cervical cap
3. Withdrawal
4. Calendar or rhythm method
5. Condoms

Every time
Most of the time
About half of the time
Some of the time
None of the time

Have you ever had sexual intercourse without using a condom at all?
1. Yes
2. No

[If yes to Q20]: Please tell us about the time(s) you have had sex without using a condom (check all that apply).

We got carried away in the moment
We didn’t have condoms readily available
I wanted to feel as close as possible to my partner
We were both virgins
My partner convinced me we didn’t need condoms
I convinced my partner we didn’t need condoms
I knew my partner well
I trusted my partner
I was drunk or high
My partner was drunk or high
My partner looked clean
My partner and I had talked about being exclusive (not having sex with others)
My partner and I had talked about our HIV status
My partner and I had talked about our STD status (STDs other than HIV)
My partner and I had gotten tested together
My partner and I had talked about what we would do in case we got pregnant

Think about your current boyfriend/girlfriend or your most recent boyfriend/girlfriend. Did you talk with this person about any of the following topics?
1. HIV or AIDS
2. STDs other than HIV, such as chlamydia or genital herpes
3. Getting tested for HIV
4. Getting tested for STDs other than HIV, such as chlamydia
5. Using condoms
6. Using birth control other than condoms
7. What you would do if you (or she) got pregnant

Has a health care provider ever suggested that you be tested for HIV?
1. Yes
2. No
3. Don’t remember

Have you ever been tested for HIV?
1. Yes, more than 12 months ago
2. Yes, in the past 12 months
3. Yes, but I can’t remember when it was
4. No
5. Don’t know

Has a health care provider ever suggested that you get tested for STDs other than HIV, such as chlamydia or gonorrhea?
1. Yes
2. No
3. Don’t remember

Have you ever been tested for STDs other than HIV, such as chlamydia or gonorrhea?
1. Yes, more than 12 months ago
2. Yes, in the past 12 months
3. Yes, but I can’t remember when it was
4. No
5. Don’t know

(If yes to 25 indicating testing for STDs): How did you know you were tested for STDs other than HIV? Check all that apply.
1. I asked to be tested
2. The doctor or nurse told me I was being tested
3. The doctor or nurse called with my results
4. It is part of my routine health care
5. Other (explain)

(If yes to 25 indicating testing for STDs): The last time you were tested for STDs other than HIV, did you specifically go to get tested for STDs, or did it happen as part of another type of health visit?
1. Specifically went to get tested
2. As part of another visit
3. Other (explain)

(If yes to 25 indicating testing for STDs): The last time you were tested for an STD, where did you receive the test?
1. Private doctor’s office
2. Family Planning Clinic or Planned Parenthood
3. School or School-based clinic
4. STD clinic
5. Community health clinic, community clinic, public health clinic
6. Some other place (specify)

(If yes to 25 indicating testing for STDs): There are a lot of reasons why people might get tested for STDs other than HIV. Check all the reasons why you were tested:
1. I was concerned that I had an STD
2. I had signs or symptoms of an STD
3. My health care provider suggested I get tested
4. A partner suggested or asked that I get tested
5. It is something I do on a regular basis
6. It just seemed like a good idea
7. Learned that a lot of people have STDs
8. It seems everyone else who’s sexually active is doing it
9. Heard about nearby testing
10. My friends were going and suggested I do it too

(If NO to 25 indicating NOT testing for STDs):There are a lot of reasons why people might NOT get tested for STDs. In the list below, place a check mark by each of the reasons that apply to you:
1. It is too expensive
2. People might think badly about me
3. I do not want my parents to find out
4. I am worried about confidentiality
5. I am not at risk for STDs
6. My doctor or health care provider has never suggested I get tested
7. I don’t want to know if I have an STD
8. I do not know where to get tested
9. I don’t know what is involved in getting tested
10. It might be painful to get tested
11. It is embarrassing or difficult to ask to be tested
12. It is inconvenient to go get tested
13. I would know if I had an STD
14. Some other reason (specify)

Have you ever been in any of the following situations?
1. Thought you might have an STD or HIV
2. Thought your partner might have an STD or HIV
3. Been given medication or a prescription for STDs by a doctor or nurse
4. Been given medication or a prescription for STDS by a doctor or nurse to give to your partner
5. Been given medication or a prescription for STDs by your partner
6. Given medication or a prescription for STDs to your partner
7. Had an STD or HIV
8. Had sex with someone who had (or thought they had) an STD or HIV
9. Had a friend or family member who had an STD
10. Had a friend or family member who had HIV

Please indicate whether you have done any of the following:
1. Talked to a health care provider about STDs or getting tested for STDs
2. Talked with someone you were involved with romantically about STDs or getting tested for STDs
3. Talked with friends about STDs or getting tested for STDs
4. Looked online for information about STDs or getting tested for STDs
5. Talked with a family member about STDs or getting tested for STDs

Are you or your current sex partner pregnant or trying to get pregnant?
1. Yes
2. No
3. I don’t know

Did you see a doctor or nurse in the past year for any of the following reasons?
	A regular check-up or physical	0	No
	when you weren’t sick or injured	1	Yes

	Sickness (like a fever or infection)	0	No
		1	Yes

	Ongoing illness (like asthma or diabetes)	0	No
		1	Yes

	An injury (like a broken bone or cut)	0	No
		1	Yes

	A sexual health checkup	0	No
		1	Yes

	Birth control	0	No
		1	Yes

	A test or treatment for an	0	No
	STD like Chlamydia,	1	Yes
	gonorrhea, herpes, or HIV

GYT Awareness and Impact

Have you ever been to a Planned Parenthood health center or clinic?

Yes, more than 12 months ago
Yes, in the past 12 months
Yes, but I don’t remember when it was
No
Don’t know

During the last year, how much, if anything, have you personally seen, heard, or read about STDs or testing for STDs? Have you heard a lot, some, only a little, or nothing at all?

A lot
Some
Only a little
Nothing at all

During the last year, do you recall seeing or hearing any ads or messages or other programming about STDs or testing for STDs?

Yes
No
Don’t know

In the past 12 months, do you recall seeing or hearing any ads or messages about STDs or testing for STDs in the following places?

Please indicate whether you have ever heard of each one of the following public service campaigns.

Above the Influence

Yes, have heard of
No, have not heard of
Don’t know

Bedsider

Yes, have heard of
No, have not heard of
Don’t know

GYT: Get Yourself Tested

Yes, have heard of
No, have not heard of

Don’t know

It’s Your (Sex) Life

Yes, have heard of
No, have not heard of
Don’t know

Lock It or Leave It
Power of 12
A Thin Line

Have you ever seen this image? [GYT LOGO]

Yes
No
Don’t know

Have you ever seen any of these images? [COMPILATION OF CAMPAIGN IMAGES]

[IF RECALL GYT] What is the campaign trying to get you to do? (Check all that apply):

Abstain from sex
Become a youth leader
Exercise
Follow my dreams
Get tested for STDs
Talk about STDs/testing with my partner
Talk about STDs/testing with a doctor or health care provider
Use condoms
None of the above
I don’t know

[IF RECALL GYT] You had mentioned that you had heard of a public service campaign called GYT: Get Yourself Tested. Do you recall seeing or hearing about GYT: Get Yourself Tested in any of the following places?

MTV
Other television network
Internet
School , including school health centers
Doctor’s office or health clinic, like Planned Parenthood
Special Event (e.g. a neighborhood party or concert)
Other

Recently there have been several media campaigns about STDs or STD testing, some of which you mentioned seeing. How big an impact do you think messages like these have on people your age? A very big impact, somewhat of an impact, not too big an impact, or no impact at all?

People talk more openly about testing
People joke more about testing and getting STDs
People think differently about testing
It has become more socially acceptable to get tested for STDs
“GYT” has become a term that people use

How much, if any, impact would messages about STDs and testing for STDs have on you personally?

A very big impact
Somewhat of an impact
Not too big an impact
No impact at all

Please tell me if programming or messages about STDs or STD testing have made you more likely or less likely to do each of the following – or if they haven’t made much difference either way.

Think more positively about getting tested for STDs

Talk openly about STDs and testing with friends

Use condoms if/when you have sex

More likely
Less likely
Haven’t made much difference either way

Talk to a partner about STDs or testing for STDs

More likely
Less likely
Haven’t made much difference either way

Talk to a doctor or health care provider about STDs or testing for STDs

More likely
Less likely
Haven’t made much difference either way

Talk to the person I’m with about STDs/testing when I see the ad/message
Get tested for STDs

More likely
Less likely
Haven’t made much difference either way

How often, if ever, do you watch MTV, including watching on TV or on a computer, tablet, smartphone, or other platform?

Every day
A couple times a week
Once a week
About once a month
Less than once a month
Never

[OF THOSE WHO WATCH MTV AT LEAST ONCE A WEEK] On average, about how much time do you spend watching MTV?

Several hours a day
About an hour a day
Several hours a week
About an hour a week
Less than an hour a week

[OF THOSE WHO EVER WATCH MTV] You mentioned earlier that you sometimes watch MTV. Do you remember seeing any public service ads or specials or other shows on MTV about STDs or testing for STDs?

Yes
No
Don’t know

Please indicate whether you have ever seen one of the following shows?
1. 16 and Pregnant

Teen Mom

Savage U

Awkward

Demographics

How old are you? (enter a number ______)

What is your sex?

Male
Female

Are you currently attending school?

Yes, High School
Yes, College
Yes, Business, Technical or Vocational School after high school
No

[If in COLLEGE] Is your college recognized as a (check all that apply):

Historically Black College or University (HBCU)
Minority Postsecondary Institution (MPI)
Hispanic Serving Institute (HSI)
Tribal College or University (TCU)
Alaskan Native or Native Hawaiian serving institution (ANNH)
Faith-based institution
Community college
Technical or trade School
None of the above
Don’t know

[If in high school] What have you gone to your school nurse or clinic for? Please mark all that apply.

E3x We don’t have a clinic or nurse at school

E3y We have a nurse or clinic but I have never been

E3a. Immunizations (shots) o No o Yes

E3b. A check-up or sports physical o No o Yes

E3c. Sickness (like a fever or infection) o No o Yes

E3d. An injury (like a broken bone or cut) o No o Yes

E3e. Ongoing illness (like asthma or diabetes) o No o Yes

E3f. A sexual health checkup o No o Yes

E3g. Birth control o No o Yes

E3h. A test or treatment for a sexually

transmitted disease (STD) o No o Yes

E3j. Information about sex o No o Yes

E3k. Condoms?

E3l. Information about my health o No o Yes

What grade of school are you currently in or what is the last grade or class you completed in school?

Are you financially dependent on your parents?
1. Totally dependent
2. Mostly dependent
3. Somewhat dependent
4. Not dependent
5. Don’t know

Who lives with you? (Check all that apply)
1. I live alone (no one lives with me)
2. Friend or friends
3. Roommate
4. Boyfriend or girlfriend
5. Fiancée or spouse
6. Siblings (brothers and sisters)
7. Parent or parents
8. Family members who are not parents or siblings
9. Landlord or tenant

Are you of Hispanic or Latino origin?

1. Yes

2. No

3. Don’t know

4. Refuse to answer

Which of the following best describes your race? (Check all that apply)

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Native Hawaiian or Other Pacific Islander

5. White

6. Don’t know

7. Refuse to answer

Do you consider yourself to be:
1. Straight or heterosexual
2. Gay or Lesbian
3. Bisexual
4. Transgender
5. “Queer”
6. Not sure
7. Other (specify:____________________)

Currently, how important is religion or spirituality in your daily life?
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all

What is your religious affiliation?
1. Roman Catholic
2. Christian but not Catholic (Protestant)
3. Jewish
4. Muslim
5. Mormon
6. Greek or Russian Orthodox
7. Atheist
8. Agnostic
9. No religious affiliation
10. Other (specify)

What language is usually spoken in your home? Check all that apply.

Do you have any kind of health care coverage, including private health insurance, prepaid plans such as HMOs, or government plans such as Medicaid or Indian Health Services? By health care coverage, we do not mean dental or vision plans, but insurance that pays for your other medical bills.
1. Yes, have private health insurance
2. Yes, have [Medicaid/name of state plan] or other government plan
3. No
4. Refused
5. Don‘t know / Not sure

Was there an adult in the room with you while you were taking this survey?

Yes, for some or all of the time
No

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Bonds, Constance (CDC/OID/NCHHSTP)
File Modified	0000-00-00
File Created	2021-01-30