Motion Comic Pre Test Survey

“Development of a Motion Comic for HIV/STI Prevention Among Young People – ages 15-24”—Phase 2

Attachment 1d. Participant Pre-Test Survey

Form Approved

OMB No. 0920-0840

Expiration Date: 02/19/2019

Development of a Motion Comic for HIV/STI Prevention Among Young People – ages 15-24—Phase 2

Attachment 1d

Participant Pre-Test Survey

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-0840)

MOTION COMIC PRE-TEST SURVEY

Study ID No. _____

A. DEMOGRAPHICS.

1. What is the first letter of your middle name? ____ (If you do not have a middle name, write ‘X’.)

2. What month were you born? Circle the month below:

January February March April May June July August September October November December

3. How old are you? ________________ years

4. What sex are you? _____ Male _____ Female _____ Transgender

5. Are you Hispanic or Latino? ____ Yes ____ No

6. If Yes, what best describes your Hispanic ancestry? (Check all that apply)

_____ Mexican

_____Puerto Rican

_____Cuban

_____Dominican

_____Other ____________________________

7. What is your race? Select one or more options of the following options.

_____ American Indian or Alaska Native

_____ Asian

_____ Black or African American

_____ Native Hawaiian or Other Pacific Islander

_____ White

8. Were you born in one of the 50 states in the United States (not including U.S. territories like Puerto Rico or Guam)? ____ Yes ____ No

9. If NO, what country or territory:

_____ US Territory (such as Puerto Rico or Guam)

North America (Not including U.S.; i.e. Canada, Mexico)

_____Central America

_____South America

_____Caribbean

_____Africa/Middle East

_____Europe

_____Asia

_____Australia/South Pacific

_____Other ____________________________

10. What is the total number of years you have been living in the U.S.?

______ Years

11. How do you identify your sexuality?

___ Homosexual/gay/lesbian

___ Heterosexual/straight

___ Bisexual

___ Not sure

12. What is your relationship status?

___Single ___Married ___Divorced ___Separated ___Domestic Partnership

12a.___ not dating anyone seriously 12b.___have a serious bf/gf/or partner

B. SEXUAL HISTORY AND ABSTINENCE/CONDOM USE INTENTIONS

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

___Yes ___No

1. Who have you had sex (anal, oral, vaginal) with? (check all that apply)

___ Men __Women ____ Transgender

2. Do you think you will have sex sometime in the next 3 months?

____ Yes ____No ____Maybe

3. Do you plan to use a condom or dental dam if you have sex in the next 3 months?

___ Yes ____No ___ No, I do not plan to have sex in the next 3 months

4. Have you had sex (anal, oral, vaginal) in the last 3 months (90 days)?

___Yes ___No (Skip to section C-Experience and attitudes about HIV Testing)

5. In the past 3 months (90 days), how many people have you had vaginal sex with? ___

6. In the past 3 months (90 days), how many people have you had anal sex with? ____

7. In the past 3 months (90 days), how many people have you had oral sex with? ____

8. Do you currently have a boyfriend/girlfriend or main partner who you are serious with?

__Yes __ No

1. How long have you been in this current relationship? ___Years ___Months ___Days

9. The last time you had vaginal sex with your main partner, did you use a condom?

__Yes __ No

10. The last time you had anal sex with your main partner, did you use a condom?

__Yes __ No

11. The last time you had oral sex with your main partner did you use a form of protection such as a condom or dental dam?

__Yes __ No

Now I would like to ask you about another partner you have had sex with who is not your main partner, a casual partner….

Have you ever had sex with a casual partner, that is, someone with whom you were not in a serious relationship or whom you did not consider a main partner?

____Yes ____No (Skip to Section C)

12. The last time you had vaginal sex with your casual partner, did you use a condom?

__Yes __ No

13. The last time you had anal sex with your casual partner, did you use a condom?

__Yes __ No

14. The last time you had oral sex with your casual partner did you use a form of protection such as a condom or dental dam?

__Yes __ No

C. EXPERIENCE AND ATTITUDES ABOUT HIV TESTING

These next set of questions will gauge your experience, attitudes and feelings about HIV testing. HIV is the virus that causes AIDS. You do not have to be sexually active to answer these questions. Please tell us how much you agree or disagree with the following statements.

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

__Yes __No (Skip to question #3)

2a. How many times have you been tested for HIV in your life? # ___

2b. What type of HIV tests have you taken (check all that apply)

___Oral ___ Finger stick ___Blood draw

2. When was your most recent test? You can estimate if you cannot remember exactly.

Month/Year ____________ ___ Don’t remember

3a. What was the result of your most recent HIV test?

___ Positive, I have HIV __ Negative, I do not have HIV __ I did not get my test results

3. Do you plan to get tested for HIV sometime in the next 3 months (90 days)?

__ Yes __ No

4. a. I am/would be too scared to get an HIV test.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

b. If I was offered a chance to get an HIV test, I would get it.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

c. Everybody who has had unprotected sex should get an HIV test.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

d. I know where to get an HIV test.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

e. I get tested for HIV regularly.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

f. I get an HIV test before I have sex with a new sex partner.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

g. I ask all new sex partners when their last HIV test was.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

h. I ask all new sex partners about the result of their last HIV test.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

i. Everyone regardless of if they are sexually active should get an HIV test.

__ Strongly agree __ Somewhat agree __ Somewhat disagree __ Strongly disagree

D. HIV STIGMA

These next set of questions will gauge your attitudes and feelings about HIV stigma. You do not have to be sexually active to answer these questions. Please tell us how much you agree or disagree with the following statements.

1. I would sit next to an HIV-positive person.

Strongly agree __ Agree __ Neither agree or disagree __ Disagree __ Strongly disagree

2. People who are HIV positive have gotten what they deserve.

Strongly agree __ Agree __ Neither agree or disagree __ Disagree __ Strongly disagree

3. I would be afraid to live with an HIV-positive person.

Strongly agree __ Agree __ Neither agree or disagree __ Disagree __ Strongly disagree

4. I would buy fruit from someone who I knew was HIV-positive.

Strongly agree __ Agree __ Neither agree or disagree __ Disagree __ Strongly disagree

5. I would not eat in a restaurant if I found out that someone who was HIV-positive worked there.

Strongly agree __ Agree __ Neither agree or disagree __ Disagree __ Strongly disagree

6. I would date someone who is HIV positive.

Strongly agree __ Agree __ Neither agree or disagree __ Disagree __ Strongly disagree

7. I would live with someone who is HIV positive.

Strongly agree __ Agree __ Neither agree or disagree __ Disagree __ Strongly disagree

E. HIV/STI KNOWLEDGE

These next set of questions will gauge your attitudes and feelings about HIV/STI knowledge. You do not have to be sexually active to answer these questions. Please tell us whether you think the following statements are true or false.

Now we will ask you to answer some questions about HIV and STI

1. You can always tell if someone has as an STI.

___True ___ False

2. All people who have been infected with HIV quickly show signs of being infected.

___True ___ False

3. You cannot get HIV by sharing knives, forks, or cups with a person who has HIV.

___True ___ False

4. Wearing a condom correctly will protect you from most STIs.

___True ___ False

5. If a woman uses birth control pills, it lowers her risk for getting HIV.

___True ___ False

6. Using oil based lubricants such as Vaseline or Crisco with condoms will reduce the risk of getting HIV/STI.

___True ___ False

7. There is no cure for HIV.

___True ___ False

8. Having another sexually transmitted disease like Gonorrhea or Herpes increases a person’s risk of becoming infected with HIV.

___True ___ False

9. Having sexual intercourse without a condom increases a person’s risk of becoming infected with HIV/STI.

___True ___ False

10. A person can get HIV by sharing a glass of water with someone who has HIV.

___True ___ False

11. There is a vaccine (shot) that can prevent people from getting HIV.

___True ___ False

12. There is a vaccine (shot) that can prevent people from getting some STIs.

___True ___ False

13. A person is likely to get HIV by deep kissing (putting their tongue in their partner's mouth) if his/her partner has HIV.

___True ___ False

14. There is a female condom that can help decrease a woman's chance of getting HIV/STI.

___True ___ False

15. A person cannot get HIV if she or he is taking antibiotics.

__True ___ False

16. I would have protected sex with someone who is HIV Positive

__True ___False

(If you answered no to question B2, survey ends here)

F. CONDOM ATTITUDES AND KNOWLEDGE

1. I know where I can obtain condoms

Strongly agree __ Agree __ Neither agree or disagree __ Disagree __ Strongly disagree

2. I don’t’ want to buy condoms because I am afraid people will know I am having sex

Strongly agree __ Agree __ Neither agree or disagree __ Disagree __ Strongly disagree

3. I am embarrassed to purchase condoms at store near where I live because people will know I am having sex

Strongly agree __ Agree __ Neither agree or disagree __ Disagree __ Strongly disagree

4. I would buy condoms if I could purchase them without anyone knowing/seeing me buy them

Strongly agree __ Agree __ Neither agree or disagree __ Disagree __ Strongly disagree

5. I would obtain condoms from a clinic if I could so anonymously

Strongly agree __ Agree __ Neither agree or disagree __ Disagree __ Strongly disagree

6. I am./would be too embarrassed to ask my partner to use a condom.

__Strongly agree __ Agree __ Neither agree or disagree __ Disagree __ Strongly disagree

7. I will/ would insist on using a condom, even if my partner did not want to use one.

__ Strongly agree __ Agree __ Neither agree or disagree __ Disagree __ Strongly disagree

G. Behavioral Intentions

1. Thinking of the occasions when you may have sexual intercourse in the next 3 months (90 days), how often do you think you will use condoms?

___Always ___Most Times ___About half the time ___occasionally __Never

___ Not planning to have sex

2. Thinking of the occasions when you may have sexual intercourse in the next 3 months (90 days), how often do you think you will talk with you partner about using condoms during sex?

___Always ___Most Times ___About half the time ___occasionally __Never

___ Not planning to have sex

3. Thinking about the next 3 months (90 days) how likely is it you will get an HIV Test

__Extremely likely ____ Likely ____ Neutral ___ Unlikely ___Extremely unlikely

4. Thinking about the next 3 months (90 days) how likely is it you will get an STI Test (Gonorrhea, Chlamydia, etc)

___ Extremely likely ____ Likely ____ Neutral ___ Unlikely ___Extremely unlikely

___ Not planning to have sex

5. How likely is it that you will remain abstinent in the next 3 months (90 days)

___Extremely likely ____ Likely ____ Neutral ___ Unlikely ___Extremely unlikely

___ Not planning to have sex

6. Thinking of the number of sex partners you have had in the last 3 months (90 days), how likely do you think you will reduce the number of partners you will have?

__ Extremely likely ____ Likely ____ Neutral ___ Unlikely ___Extremely unlikely

___ Not planning to have sex