Form Approved
OMB No. 0920-0840
Exp. Date 02/29/2016
Submission 0920-13ABP under
0920-0840 Formative Research and Tool Development
Attachment 2p: Paper and Pencil- HIV Testing
Survey Instrument
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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0840).
Attachment 2p: Paper and Pencil- HIV Testing
CASE ID_____________
PARTICIPANT SURVEY
We are interested in your opinions about HIV testing. We would also like to get some additional information about you. If you’re not sure, choose an answer that comes closest to what you think might be true for each question. Please remember that your answers are private. You can choose not to answer any question and can stop at any time. When you are finished with the survey, please place it in the envelope.
1. How old are you?
Age__________
a. Refuse to answer
2. What is your gender?
a. Male
b. Female
c. Transgender or Transsexual
d. Other [Specify: ] [Terminate]
e. Don’t know [Terminate]
f. Refuse to answer [Terminate]
What was your sex at birth?
1 Male
2 Female
3 Intersex/ambiguous
9 Refused to answer
Do you consider yourself to be male, female, or transgender?
1 Male
2 Female
3 Transgender or two-spirited
9 Refused to answer
Are you Hispanic or Latino/a
a. ____No
b. ____Yes
c. Prefer not to answer
What is your race? (One or more categories may be selected)
a. ____White
b. ____Black or African American
c. ____American Indian or Alaska Native
d. ____Asian
e. ____Native Hawaiian or Other Pacific Islander
f. Prefer not to answer
In what country or territory were you born?
1 United States [SKIP TO S7]
2 Puerto Rico
3 Mexico
4 Cuba
5 Other (Specify: )
9 Refused to answer
How many years have you been living in the United States? (If less than one year, put a 0 in the space.)
years
What language are you most comfortable using with your family and friends?
1 English
2 Spanish
3 English and Spanish equally
4 Other (Specify: )
9 Refused to answer
5. What is the highest grade or year of school you finished?
a. Never attended school or only attended kindergarten
b. Grades 1 through 8 (elementary)
c. Grades 9 through 11 (some high school)
d. Grade 12 or GED (high school graduate)
e. College 1 year to 3 years (some college or technical school)
f. College 4 years or more (college graduate)
g. Refuse to answer
6. Which best describes your total personal income during the past year?
a. Less than $20,000
b. $21,000 to $30,000
c. $31,000 to $40,000
d. $41,000 to $50,000
e. $51,000 or more
f. Refuse to answer
7. Which do you consider yourself to be?
a. Gay, lesbian, homosexual, or same gender loving
b. Bisexual or two spirited
c. Straight or heterosexual
d. Other [Specify: ]
e. None of the above/unsure
f. Refuse to answer
8. What is your current relationship status? Are you…?
a. [Single]
b. [Married to a man]
c. [Married to a woman]
d. [In a relationship with a man]
e. [In a relationship with a woman]
f. [Divorced or widowed]
g. Refuse to answer
9. In what ZIP code do you currently live? _________
10. Before being contacted for this study, had you ever heard of CDC or the Centers for Disease Control and Prevention?
a. Yes
b. No
e. Refuse to answer
Sources of Information
The first set of questions asks about how you may get certain kinds of information.
11. Please tell us whether you’d be interested in getting information about HIV testing from each of the following sources. [MARK ALL THAT APPLY]
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Yes |
No |
a. Community health clinic |
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b. Doctor’s office |
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c. Church |
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d. Health fair |
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e. Work |
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f. Sporting event |
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g. Night club |
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h. [Gay bookstore] |
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i. Coffee shop |
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j. Clothing store |
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k. Health club or gym |
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l. [Choirs or choruses] |
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m. Shopping malls |
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n. [Black pride events] |
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o. [Circuit Parties (Sizzle Miami, Houston Splash, Oasis, Datboi Spring Fling Las Vegas, Fire Island Black Out, St. At Large)] |
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p. [Balls] |
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q. [Sex shops] |
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r. [Bath houses] |
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s. [Clubs/party promoters (Men are from Mars, Wassup N ATL)] |
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t. [Gay newspaper] |
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12. Do you use the Internet?
a. Yes
b. No (Skip to Question 16)
Imagine you are looking online for information about where to find an HIV test near you. Your search revealed the following websites. Which would you be most likely to visit?
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Very Unlikely |
Some-what Likely |
Neither Unlikely or Likely |
Some-what Likely |
Very Likely |
Refuse to Answer |
a. AIDS.gov |
1 |
2 |
3 |
4 |
5 |
9 |
b. HIVtest.org |
1 |
2 |
3 |
4 |
5 |
9 |
c. ActAgainstAIDS.org |
1 |
2 |
3 |
4 |
5 |
9 |
d. Other ( ) |
1 |
2 |
3 |
4 |
5 |
9 |
15. How often do you visit the following Web sites?
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Daily |
2 -5 Times a week |
Once a week |
2-3 Times a month |
Once a month |
Less than once a month |
Never |
a. Facebook (www.facebook.com) |
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b. Myspace (www.myspace.com) |
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c. YouTube (www.youtube.com) |
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d. [insert] |
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e. [insert] |
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f. [insert] |
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g. [insert] |
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h. [insert] |
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i. [insert] |
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j. [insert] |
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k. Other: [Specify:___________] |
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l. Other: [Specify:___________] |
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Are there other websites or mobile services that you use on a daily basis?
Please tell us if you agree or disagree with the following statement: I trust the CDC as the source of this information.
1 Strongly disagree
2 Disagree
3 Neither disagree nor agree
4 Agree
5 Strongly Agree
9 Refuse to answer
16.
These next few questions are about your personal behaviors, including sexual activity. Please remember that your answers are kept private.
Sexual Activity
21.
25. Did you have [oral/vaginal/anal sex] with any of your [female/male] partner(s) in the past [INSERT TIME FRAME]?
a. Yes
b. No
c. Refuse to answer
26. When you had [oral/vaginal/anal] sex with your [female/male] partner(s) in the past [INSERT TIME FRAME], how often did you and your partner use a condom?
a. Never used a condom
b. Occasionally used a condom
c. Usually used a condom
d. Always used a condom
e. Refuse to answer
27. In the past [INSERT TIME FRAME], did you ever, even one time, have sex without a condom?
a. Yes
b. No
d. Refuse to answer
Sexual Partners
28. Do you currently have a main sex partner—that is, a partner you would call your spouse, significant other, or life partner?
a. Yes
b. No
c. Refuse to answer
29.
30. Is your main partner male, female, or transgender?
a. Male
b. Female
c. Transgender
d. Refuse to answer
31. What is your main partner’s HIV status?
a. My main partner is HIV negative
b. My main partner is HIV positive
c. My main partner has not been tested for HIV
d. My main partner has not told me his or her HIV status
e. Refuse to answer
Why did you think that they were this status? (CHECK ALL THAT APPLY)
1 They told me explicitly
2 I guessed based on other things they talked about
3 Someone else told me
4 By their appearance
5 We got tested together [ERROR CHECK IF Q24=3]
6 I saw their results [ERROR CHECK IF Q24=3]
7 I went with them to get their results [ERROR CHECK IF Q19=3]
8 Other (Specify: )
9 Refuse to answer
32. Does your main partner know your HIV status?
a. Yes
b. No
c. Refuse to answer
Thinking about your main male sex partner, do you consider him to be at low, medium or high risk for getting HIV? [IF Q8=2 (POSITIVE), SKIP]
1 Low risk
2 Medium risk
3 High risk
9 Refuse to answer
Some couples develop agreements about whether, when, and with whom sex outside the relationship is okay. Which one of the following scenarios best describes any agreements that you and your main partner have?
1 Both of us cannot have any sex with an outside partner
2 We can have sex with outside partners but with some restrictions
3 We can have sex with outside partners without any restrictions
4 We do not have an agreement
9 Refuse to answer
33. In the past 12 months, how many non-main partners – that is, somebody who you did not consider to be a spouse, significant other, or life partner – did you have oral, vaginal, or anal sex with?
a. 0
b. 1-5
c. 6-10
d. 11-15
e. 16-20
f. Over 20
g. Refuse to answer
How often did you and your last non-main male sex partner use condoms for anal sex?
1 Never
2 Occasionally
3 Usually
4 Always
9 Refuse to answer
What is your last non-main male sex partner’s HIV status?
1 He is HIV negative
2 He is HIV positive
3 He has not been tested for HIV
4 He has not told me his or her HIV status [SKIP TO Q25]
9 Refuse to answer [SKIP TO Q25]
Why did you think that he was this status? (CHECK ALL THAT APPLY)
1 He told me explicitly
2 I guessed based on other things he talked about
3 Someone else told me
4 By his appearance
5 We got tested together [ERROR CHECK IF Q23=3]
6 I saw his results [ERROR CHECK IF Q23=3]
7 I went with him to get his results [ERROR CHECK IF Q23=3]
8 Other (Specify: )
9 Refuse to answer
Thinking about your last non-main male sex partner, do you consider him to be at low, medium or high risk for getting HIV? [IF Q23=2 (POSITIVE), SKIP Q25]
1 Low risk
2 Medium risk
3 High risk
9 Refuse to answer
34. Did you have unprotected [vaginal/anal] sex with any [female/male] partners in the past 12 months whose HIV status you didn’t know? By unprotected sex, I mean [oral/vaginal/anal] sex when you or your partner didn’t use a condom.
a. Yes
b. No
c. Refuse to answer
35. Did you have unprotected [vaginal/anal] sex with any [female/male] partners in the past 12 months who you knew or thought to be HIV positive? By unprotected sex, I mean [oral/vaginal/anal] sex when you or your partner didn’t use a condom.
a. Yes
b. No
c. Refuse to answer
36.
In the past 12 months, how often did you look for male sexual partners with same HIV status as you?
1 Never
2 Occasionally
3 Usually
4 Always
9 Refuse to answer
In the past 12 months, how often did use your HIV status and your male partner’s HIV status to determine which sexual roles (i.e., insertive/top or receptive/bottom) and activities (i.e., oral and anal intercourse) you would engage in?
1 Never
2 Occasionally
3 Usually
4 Always
9 Refuse to answer
In the past 12 months, how often have you had unprotected anal sex with a male partner … (By unprotected anal sex, we mean any anal sex without a condom).
|
Never |
Occasionally |
Usually |
Always |
Refuse to Answer |
a. Who you knew or thought was HIV positive? |
1 |
2 |
3 |
4 |
9 |
b. Whose HIV status you did not know |
1 |
2 |
3 |
4 |
9 |
During the past 12 months how many times did you get an HIV test?
NUMBER __________
9 Refuse to answer
How sure are you that you could get an HIV test if:
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Very Sure I Could Not |
Some-what Sure I Could Not |
Neither Unsure or Sure I Could |
Some-what Sure I Could |
Very Sure I Could |
Refuse to Answer |
a. You could find a free testing site online that is near you |
1 |
2 |
3 |
4 |
5 |
9 |
b. You knew your results would be kept confidential |
1 |
2 |
3 |
4 |
5 |
9 |
c. You had to travel far to find a free testing site |
1 |
2 |
3 |
4 |
5 |
9 |
d. You could find an HIV test provider that speaks your language, e.g., English, Spanish |
1 |
2 |
3 |
4 |
5 |
9 |
e. You could find an HIV test provider that has interpreter/translation services |
1 |
2 |
3 |
4 |
5 |
9 |
f. You could find a provider that looks like you |
1 |
2 |
3 |
4 |
5 |
9 |
[Positive Attitudes toward Talking about HIV]
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Strongly Disagree |
Disagree |
Neither Disagree nor Agree |
Agree |
Strongly Agree |
Refuse to Answer |
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1 |
2 |
3 |
4 |
5 |
9 |
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1 |
2 |
3 |
4 |
5 |
9 |
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1 |
2 |
3 |
4 |
5 |
9 |
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1 |
2 |
3 |
4 |
5 |
9 |
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1 |
2 |
3 |
4 |
5 |
9 |
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1 |
2 |
3 |
4 |
5 |
9 |
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1 |
2 |
3 |
4 |
5 |
9 |
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1 |
2 |
3 |
4 |
5 |
9 |
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1 |
2 |
3 |
4 |
5 |
9 |
[Sexual Orientation and Discrimination]
Have you ever told anyone that you are attracted to or have sex with men?
1 No
2 Yes
9 Refuse to answer
Which of the following people have you told that you are attracted to or have sex with men?
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Yes |
No |
Refuse to Answer |
a. Gay, lesbian, or bisexual friends |
1 |
2 |
9 |
b. Friends who are not gay, lesbian, or bisexual |
1 |
2 |
9 |
c. Family members |
1 |
2 |
9 |
d. Health care providers |
1 |
2 |
9 |
e. A religious or spiritual leader such as a priest or minister |
1 |
2 |
9 |
During the past 12 months, how often have any of the following things happened to you because someone knew or assumed you were attracted to men?
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Never |
Occasionally |
Usually |
Always |
Refuse to Answer |
a. You were called names or insulted |
1 |
2 |
3 |
4 |
9 |
b. You received poorer services than other people in restaurants, stores, other businesses or agencies |
1 |
2 |
3 |
4 |
9 |
c. You were treated unfairly at work or school |
1 |
2 |
3 |
4 |
9 |
d. You were denied or given lower quality health care |
1 |
2 |
3 |
4 |
9 |
e. You were physically attacked or injured |
1 |
2 |
3 |
4 |
9 |
How strongly do you agree or disagree with the following statement: “Most people in the neighborhood where I live are tolerant of gays and bisexuals.”
1 Strongly disagree
2 Disagree
3 Neither disagree nor agree
4 Agree
5 Strongly agree
9 Refuse to answer
Risk
Thinking about the sex you’ve had over the past (insert time frame), do you consider yourself to be high, medium or low risk for [getting or giving] HIV?
a. Low risk
b. Medium risk
c. High risk
d. Refuse to answer
If you don’t change any HIV-related behaviors what is your chance of getting HIV disease in the next (insert time period here)?
a. 0-24% or have little to no chance of getting it
b. 25-49% or have some chance of getting it
c. 50% or have equal chance of getting it or not getting it
d. 51-74% or have a good chance of getting it
e. 75-100% or it is likely that I will get it
f. Refuse to answer
43. Have you ever been tested for HIV?
a. Yes
b. No
c. Don’t know
d. Refuse to answer
44. When was your last HIV test?
0–2 months ago
3–6 months ago
7–12 months ago
More than 12 months ago
Don’t know
Refuse to answer
45. How often do you get an HIV test?
a. Every 0-2 months
b. Every 3-6 months
c. Every 7-12 months
d. Less often than once a year
e. Other [Specify: ]
f. Don’t know
g. Refuse to answer
46. When should you get an HIV test after having unprotected sex [with a woman/man]?
a. [0–2 months after having unprotected sex]
b. [3–6 months after having unprotected sex]
c. [7–12 months after having unprotected sex]
d. [More than 12 months after having unprotected sex]
e. [When you start to feel sick]
f. Refuse to answer
47. Where did you have your last HIV test?
a. Private doctor
b. STD or AIDS clinic or testing site
c. Hospital or emergency room
d. Public health department
e. Community health center
f. At home
g. Drug treatment facility
h. Other location
i. Don’t know
j. Refuse to answer
48. Which of these are the main reasons for your last HIV test? Please select one or more of the following reasons. [MARK ALL THAT APPLY.]
a. It just seemed like a good idea
b. It’s something you do every year
c. Just to find out
d. Worried that you are infected
e. A doctor, nurse, or other health care provider asked you to
f. The health department asked you to
g. Your sex partner asked you to
h. Because of pregnancy
i. To get birth control
j. You found out your sex partner cheated
k. Already had an STD
l. You were starting a new relationship
m. You get tested during your yearly exam
n. A family member or friend was diagnosed with HIV
o. Other reason [Specify:__________]
p. Don’t know
q. Refuse to answer
49. Where can you get an HIV test?
a. HIV counseling and testing site
b. STD clinic
c. Hospital
d. Community health clinic
e. Private physician office
f. Drug treatment program
g. Correctional facility (jail or prison)
h. Military
i. Other [Specify: ]
j. Don’t know
k. Refuse to answer
50. Do you get an HIV test after any situation when you think you might have been exposed to HIV?
a. Yes
b. No
c. Don’t know
d. Refuse to answer
51. Below is a list of reasons why some people have not been tested for HIV. Which of these are the main reasons why you have not been tested? Please select one or more of the following reasons. [MARK ALL THAT APPLY.]
a. You have not been sexually active
b. Your doctor never recommended it
c. You have not had unprotected sex
d. You were afraid to find out if you were HIV positive
e. You didn’t want to think about HIV or about being HIV positive
f. You didn’t think you were at risk of being HIV positive
g. You don’t like needles or giving blood
h. You don’t trust the results to be kept private
i. You had to wait too long for the results
j. You didn’t know where to get tested
k. You trust your sex partner
l. You don’t care about the results
m. You are worried about being labeled as HIV positive
n. Some other reason [Specify:__________]
o. Don’t know
p. Refuse to answer
52. Which of these are the main reasons for your last HIV test? Please select one or more of the following reasons. [MARK ALL THAT APPLY.]
a. It just seemed like a good idea
b. It’s something you do every year
c. Just to find out
d. Worried that you are infected
e. A doctor, nurse, or other health care provider asked you to
f. The health department asked you to
g. Your sex partner asked you to
h. Because of pregnancy
i. To get birth control
j. You found out your sex partner cheated
k. Already had an STD
l. You were starting a new relationship
m. You get tested during your yearly exam
n. A family member or friend was diagnosed with HIV
o. Other reason [Specify:__________]
p. Don’t know
q. Refuse to answer
The next question is about the result of your HIV test. What was the result of your most recent HIV test?
1 I tested positive for HIV [GO TO S11a]
2 I tested negative for HIV [GO TO S11b]
3 My results were unclear / Don’t Know [GO TO S11b]
4 I never got my results [GO TO S11b]
9 Decline to answer [TERMINATE AND GO TO CLOSING]
[IF POSITIVE] When did you first test positive? DATE (mm/yy):__________
9 Decline to answer
[IF NEGATIVE] When was your last HIV test?
1 Within past 1-2 months
2 Between 3-6 months ago
3 Between 7-12 months ago
4 Between 1-3 years ago
5 More than 3 years ago
9 Decline to answer
[FOR HIV-NEGATIVE MEN ONLY. IF S11=1, SKIP Q42—Q52]
[HIV TESTING: Norms & Attitudes/Perceived & Actual Knowledge/Self-Efficacy]
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Strongly Disagree |
Disagree |
Neither Disagree nor Agree |
Agree |
Strongly Agree |
Refuse to Answer |
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1 |
2 |
3 |
4 |
5 |
9 |
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1 |
2 |
3 |
4 |
5 |
9 |
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1 |
2 |
3 |
4 |
5 |
9 |
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1 |
2 |
3 |
4 |
5 |
9 |
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1 |
2 |
3 |
4 |
5 |
9 |
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1 |
2 |
3 |
4 |
5 |
9 |
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1 |
2 |
3 |
4 |
5 |
9 |
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1 |
2 |
3 |
4 |
5 |
9 |
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1 |
2 |
3 |
4 |
5 |
9 |
HIV Testing Behavioral Intentions
53. How likely is it that you will get tested for HIV in the next [12] months?
a. Very likely
b. Somewhat likely
c. Neither likely or unlikely
d. Somewhat unlikely
e. Very unlikely
HIV Testing Norms, Attitudes and Beliefs
54. On a scale from 1 to 6, where 1 is extremely bad and 6 is extremely good, how would you rate getting tested for HIV at least every [12] months?
Extremely Bad |
2 |
3 |
4 |
5 |
Extremely Good |
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55. On a scale from 1 to 6, where 1 is extremely harmful and 6 is extremely beneficial, how would you rate getting an HIV test at least every [12] months?
Extremely Harmful |
2 |
3 |
4 |
5 |
Extremely Beneficial |
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56. How sure are you that you could get an HIV test at least every [12] months if…
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Very sure I could not |
Somewhat sure I could not |
Slightly sure I could |
Somewhat sure I could |
Very sure I could |
a. you wanted to get an HIV test at least every [12] months? |
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b. you could find a free testing site? |
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c. you had to travel far to find a free testing site? |
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d. you could get the results of your HIV test within 20 minutes? |
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e. you knew that your results would be kept confidential? |
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57. Please tell us how much you disagree or agree with each of the following statements.
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Strongly disagree |
Disagree |
Neither disagree or agree |
Agree |
Strongly agree |
a. Most people who are important to me think I should get tested for HIV at least every [12] months. By important to me, we mean people like friends, family, and anyone else who is an important part of your life. |
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b. Most of my sexual partners get tested for HIV at least every [12] months. |
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c. Most [men/women] I know get tested for HIV at least every [12] months. |
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58. Please tell us how much you disagree or agree with each of the following statements: “Getting tested at least every [12] months….”
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Strongly disagree |
Disagree |
Neither disagree or agree |
Agree |
Strongly agree |
a. is expensive. |
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b. reassures me that I can get into treatment early if I test positive. |
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c. is inconvenient. |
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d. allows me to have unprotected sex with partners who are HIV negative. |
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59. How often do you think someone should get tested for HIV if they…
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Every |
Every |
Every |
Every couple of years |
Don’t know |
a. Always have sex with a condom |
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b. Have had [vaginal/anal] sex without a condom |
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c. Have a sex partner who is HIV positive |
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d. Have unprotected [anal/vaginal/oral] sex with a partner whose HIV status they don’t know |
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e. Have had more than one sex partner since their last HIV test |
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f. Exchange sex for drugs |
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Positive Attitudes toward Talking about HIV with Partners, Peers, and Family
60. It is important to talk about [HIV testing].
a. Strongly disagree
b. Disagree
c. Neither disagree nor agree
d. Agree
e. Strongly agree
f. Refuse to answer
61. It is important to talk about [HIV testing] with [INSERT].
a. Strongly disagree
b. Disagree
c. Neither disagree nor agree
d. Agree
e. Strongly agree
f. Refuse to answer
62. I am confident that I can talk to [INSERT] about [HIV testing].
a. Strongly disagree
b. Disagree
c. Neither disagree nor agree
d. Agree
e. Strongly agree
f. Refuse to answer
This next set of questions asks about how you identify in terms of race and sexual orientation. Some of the questions also ask about your experiences with how others have reacted to your race and/or sexual orientation.
63. Please tell us how much you disagree or agree with each of the following statements.
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Do not agree at all |
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Agree Completely |
a. I feel good about being a [insert race/ethnicity/sexual orientation]. |
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b. I often regret that I am a [insert race/ethnicity/gender] |
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c. In general, I am glad to be a [insert race/ethnicity/sexual orientation] |
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d. Overall, I often do not like being a [insert race/ethnicity/sexual orientation] |
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e. Being a [insert race/ethnicity/sexual orientation] is important to me |
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f. If someone says something bad about [insert race/ethnicity/sexual orientation]they say something bad about me |
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64.
65.
Thank you for answering these questions. Please place the survey in the envelope provided. Give the survey and your consent form to the interviewer when you go into the interview room. The interviewer will not see your responses to these questions.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Poehlman, Jon |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |