Enrollment Day Survey

Form Approved

OMB No. 0920-0840

Expiration Date 02/29/2016

“Evaluating a HIV/AIDS Focused Video Game for Young People”

Attachment 3b. Enrollment Day 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)

ENROLLMENT DAY SURVEY

Study ID No. _____

1. Demographics

A1: What grade are you in at school? _______

2. Experience and Attitudes About HIV Testing

The next set of questions will ask about your attitudes and feelings about HIV testing. Please tell us how much you agree or disagree with the following statements.

B1: Have you ever been tested for HIV? HIV is the virus that causes AIDS.

Yes (if yes go to B2)

No (if no go to B3)

Don’t know

B2: 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

B3: Do you plan to get tested for HIV in the next 3 months (90 days)?

Yes

No

Don’t know

B4: I am too scared to get an HIV test.

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

B5: If I was offered a chance to get an HIV test, I would get it.

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

B6: Everybody who has had unprotected sex should get an HIV test.

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

B7: I know where to get an HIV test.

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

3. HIV Stigma

The next set of questions will ask about your attitudes and feelings about people who are living with HIV. Please tell us how much you agree or disagree with the following statements.

C1: I would sit next to an HIV-positive person.

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

C2: People who are HIV-positive have gotten what they deserve.

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

C3: I would be afraid to live with an HIV-positive person.

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

C4: I would buy fruit from someone who I knew was HIV-positive

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

C5: I would not eat in a restaurant if I found out that someone who was HIV-positive worked there.

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

C6: I would date someone who is HIV-positive.

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

C7: I would live with someone who is HIV-positive.

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

D. HIV Knowledge

The next set of questions will be about your understanding of HIV and sexually transmitted infections (STIs). Please mark whether you think the following statements are true or false.

D1: You can always tell if someone has HIV.

True

False

D2: All people who have been infected with HIV quickly show signs of being infected.

True

False

D3: You cannot get HIV by sharing knives, forks or cups with a person who has HIV.

True

False

D4: Wearing a condom correctly will protect you from most STIs.

True

False

D5: If a woman uses birth control pills, it lowers her risk of getting HIV.

True

False

D6: Using oil based lubricants such as Vaseline or Crisco with condoms will reduce the risk of getting HIV or another STI.

True

False

D7: There is no cure for HIV.

True

False

D8: Having another STI like Gonorrhea or Herpes increases a person’s risk of becoming infected with HIV.

True

False

D9: Having sex without a condom increases a person’s risk of becoming infected with HIV.

True

False

D10: A person can get HIV by sharing a glass of water with someone who has HIV.

True

False

E. Behaviors

Intro: Now we want to ask you some questions about boyfriends, girlfriends, and sex. Please try to answer every question honestly. It is important for us to know what has really happened in your life, so it will help us a lot if you answer truthfully. Remember – even if you’ve answered these questions before, please think back to your whole life and answer the questions about kissing, touching and other things you have ever done with boys or girls. Your answers are very important to us.

E1: Have you ever had a close romantic relationship with a boy or girl and thought of him or her as your boyfriend or girlfriend?

Yes

No

E2: Have you ever felt like you were in love romantically with a boy or girl?

Yes

No

E3: Have you ever kissed a boy or girl in a romantic or sexy way?

Yes

No

E4: Has a boy or girl ever touched your private parts?

Yes

No

E5: Have you ever touched a boy or girl’s private parts?

Yes

No

[If the answers to the last two questions are both NO, then skip the next questions on sex]

E6: Have you ever had sex or made love to a boy or girl?

Yes

No

E7: The first time you ever had sex, if you are a boy, did you wear a condom? Or if you are a girl and had sex with a boy, did he wear a condom?

Yes

No

6. Behavioral Intentions

The next set of questions will ask about your whether or not you think you will have sex in the next 6 months.

F1: Do you think you will have sex sometime in the next 6 months?

Yes (if yes go to F2)

No (if no go to G1)

F2: How often do you think you will use a condom if you have sex in the next 6 months?

Never

Occasionally

About half the time

Most times

Always