Evaluating Social Marketing Campaigns Targeting Gay/Bisexual Men

Form Approved 
OMB No. 0920­0920 
Expiration Date 2/28/15 
Public reporting burden of this collection of information is estimated to average 2 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 D­74, Atlanta, Georgia 
30333; Attn: OMB­PRA (0920­0920) 

We are asking people to be in a research study that will help us learn more about what communication campaigns 
people may have seen and what people think about HIV prevention and testing messages. RTI International, a research 
company in North Carolina, and ICF International Inc., a research company in Atlanta, GA; are conducting the study. 
The Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia is funding the research. This survey is being 
administered by Community Marketing Inc. 

To see if you are a good match for this study, we will need to ask you some personal questions. Some of the questions 
will be about your sexual orientation and your HIV status. It is your choice to answer the questions. Your answers will 
be kept private to the extent allowed by law. You can refuse to answer any question or stop at any time. 

1. May we ask you the questions to see if you are a good match for this study?
j Yes
k
l
m
n
j No
k
l
m
n

2. How old are you?

j Don't know
k
l
m
n

j Prefer not to answer
k
l
m
n

Age 

3. What was your sex at birth?

j Male
k
l
m
n

j Female
k
l
m
n

j Intersex/ambiguous
k
l
m
n

j Don't know
k
l
m
n

j Prefer not to answer
k
l
m
n

4. Do you consider yourself to be male, female, or transgender? (check only one)

j Male
k
l
m
n

j Female
k
l
m
n

j Transgender
k
l
m
n

j Don't know
k
l
m
n

j Prefer not to answer
k
l
m
n

5. Are you of Hispanic or Latino origin?
j Yes
k
l
m
n
j No
k
l
m
n

j Prefer not to answer
k
l
m
n

6. Please indicate your race. Are you? You may select one or more races.
c White
d
e
f
g

c Black or African American
d
e
f
g
c Asian
d
e
f
g

c Native Hawaiian or Other Pacific Islander
d
e
f
g

c American Indian or Alaska Native
d
e
f
g
c Don’t know
d
e
f
g

c Prefer not to answer
d
e
f
g

7. In what ZIP Code do you currently live?

8. Which do you consider yourself to be?

j Gay or homosexual
k
l
m
n
j Bisexual
k
l
m
n

j Straight or heterosexual
k
l
m
n
j Prefer not to answer
k
l
m
n

Other (Specify) 

9. Have you ever been tested for HIV? An HIV test checks whether someone has the virus
that causes AIDS.
j Yes
k
l
m
n
j No
k
l
m
n

j Prefer not to answer
k
l
m
n

10. When did you have your first HIV test?
DATE (MM/YYYY):

11. In the past 2 years, that is, since [insert calculated month and year], how many times
have you been tested for HIV?

12. When did you have your most recent HIV test?
DATE (MM/YYYY):

13. The next question is about the result of your HIV test. What was the result of your most
recent HIV test?

j I tested positive for HIV.
k
l
m
n

j I tested negative for HIV.
k
l
m
n

j My results were unclear.
k
l
m
n

j I never got my results/Don’t know
k
l
m
n
j Prefer not to answer
k
l
m
n

14. [IF POSITIVE] When did you first test positive?
j Prefer not to answer
k
l
m
n

DATE (MM/YYYY): 

15. Have you had oral sex (mouth on the penis or vagina), vaginal sex (penis in the
vagina), or anal sex (penis in the butt) with a woman in the past 12 months?
j Yes
k
l
m
n
j No
k
l
m
n

j Prefer not to answer
k
l
m
n

16. Have you had oral sex (mouth on the penis) or anal sex (penis in the butt) with a man in
the past 12 months?
j Yes
k
l
m
n
j No
k
l
m
n

j Prefer not to answer
k
l
m
n

17. Would you like to participate in this survey?
j Yes
k
l
m
n
j No
k
l
m
n

[If Ineligible, terminate with message below] 

"Thank you for answering all of the questions. Those are all of the questions we have for you today. Thank you for being 
willing to help us." 

[Otherwise continue to survey]