Form Approved
OMB No. 0920-0895
Exp. Date: XX/XX/XXXX
“Community-based Organization (CBO) Monitoring and Evaluation Project of Respect (CMEP-Respect)”
90-Day Follow-up Survey
Attachment 3a
Public reporting burden of this collection of information is estimated to average 18 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 (0920-0895).
Form Approved OMB No. 0920-0895
Exp. Date:
CMEP-RESPECT 90-day DATA COLLECTION: General Information
(to be completed by staff)
The following section should be completed by CMEP-RESPECT staff.
Review all agency files for the client to determine which of your agency’s programs and/or activities the client has participated in. To determine what HIV-related activities the client received from other sources, you will need to ask the client directly.
G1. Client ID: ___ ___ ___ ___ [This number cannot be longer than 4 digits]
G2. CMEP-RESPECT Staff ID: ____________
G3. Data collection date: __ __/__ __/__ __ __ __
(MM/DD/YYYY)
G4. Data collection site: _______________ [Please use the appropriate site name from the list of site names established by your agency.]
G4a. What is the name of your agency?
CAP [Only use IDs 2000-2999]
Fenway [Only use IDs 4000-4999]
FROST’D [Only use IDs 6000-6999]
Life Foundation [Only use IDs 8000-8999]
G5. Data collection time point: (Choose one)
Baseline
Follow-up 1 (90-day)
Follow-up 2 (180-day)
G6. Data administered by: (Choose one)
Client
Provider (in-person)
Provider (on phone)
G7. Data collection method: (Choose one)
Laptop
Handheld device
Hard copy
Desktop
Tablet
G8. In the past 3 months, has the client… (Choose all that apply) [This refers to activities that the client has participated in during the three months prior to today’s encounter. E.g., if the client will receive HIVCTR today, and did not receive HIVCTR at any other time in the last 3 months, DO NOT select HIVCTR here.]
Received HIV Case Management Services
Received Comprehensive Risk Counseling and Services (CRCS) [If selected, please answer G9]
Received HIV Counseling, Testing and Referral (HIVCTR)
Received Partner Services
Client has not participated in any of the activities listed above in the past 3 months
[Questions G9 and G10 are asked only at Follow-up 1 and Follow-up 2]
[Do not ask G9 if “Received Comprehensive Risk Counseling and Services (CRCS)” was not selected in G8. If it was not selected skip to G11]
G9. Was Comprehensive Risk Counseling and Service (CRCS) received in conjunction with the RESPECT intervention? That is, the CRCS sessions utilized or built upon the specific risk reduction step developed during RESPECT? (This only refers to the cycle of RESPECT being evaluated as part of CMEP. It does not refer to other cycles of RESPECT delivered outside of the intervention cycle being evaluated through CMEP.)
Yes [If selected, please answer G10]
No [If the response is ‘no’, skip to question G11]
[G10 is only asked if the response was ‘yes’ in G9]
G10. How many CRCS sessions did the client receive in conjunction with RESPECT? _____
G11. In the past 3 months, has the client participated in or received the following… (Choose all that apply) (The HIV prevention behavioral interventions that a client participated in may be called a different name at each agency. If the client doesn’t know the name of the intervention they received, ask them to describe the intervention and where they received it, so that you can determine which intervention was received. If it is unclear if the intervention was a CDC effective behavioral intervention or not, you should select ‘Participated in a HIV prevention behavioral intervention that was not a CDC effective behavioral intervention’.)
HIV prevention behavioral intervention that wasn’t a CDC effective behavioral intervention [E.g., a face-to-face individual or group discussion about HIV prevention, HIV testing or safer sex practices, including homegrown interventions] [Do not select if the client participated in a CDC effective behavioral intervention or if the client participated in an online discussion about HIV prevention as these are separate response choices below.]
CDC effective behavioral intervention [Must be selected to proceed to question G12. If it is not selected, skip to question G13 at Baseline and G14 at Follow-up 1 and 2.]
On-line discussion about HIV prevention, HIV testing or safer sex practices
Condoms or a safe sex kit
Written information about HIV/AIDS or STDs
Other HIV prevention services (specify ____________________)
No participation in above activities
Don’t know
[G12 should only be asked if ‘CDC effective behavioral intervention’ was selected in G11. If it was not selected, at Baseline skip to question G13, and at Follow-up 1 and Follow-up 2, skip to question G14.]
G12. Which CDC effective behavioral intervention did the client participate in during the last 3 months? (Choose all that apply) (The HIV prevention behavioral interventions that a client participated in may be called a different name at each agency. If the client doesn’t know the name of the intervention they received, ask them to describe the intervention and where they received it, so that you can determine which intervention was received. ) (The RESPECT response choice DOES NOT refer to the RESPECT session being evaluated by CMEP. It refers to other RESPECT intervention cycles that the client received in the past 3 months outside of the RESPECT cycle evaluated by CMEP.)
Clear RAPP
Connect RESPECT
d-up: Defend Yourself! Safe in the City
Focus on Youth + IMPACT Safety Counts
Healthy Relationships SHIELD
Holistic Health Recovery Program SIHLE
Many Men, Many Voices SISTA
MIP Sister to Sister
MPowerment Street Smart
Nia Together Learning Choices
Partnership for Health VOICES/VOCES
Popular Opinion Leader WILLOW
Project Start Other (specify)_______________
PROMISE Don’t know
[Question G13 is asked only at Baseline]
G13. Within the 24 hours prior to receiving the outcome monitoring questionnaire, did the client participate in either HIV Counseling Testing and Referral (CTR) OR engage in a conversation with a staff member from your agency about factors that place them at risk for contracting or transmitting HIV? (Choose all that apply) (This includes discussions of risk factors during the initial client encounter/agency intake or any other substantive discussion of risk. It is important to review the client’s chart to determine if another staff member at your agency may have had these types of discussions with the client. Please note that this does not include asking the client questions about their risk as part of determining eligibility.)
Yes, the client received HIVCTR in the last 24 hours [If this is selected, then on question G8, the response choice “Received HIV Counseling Testing and Referral (CTR)” must be selected.]
Yes, the client engaged in a conversation with a staff member about factors that placed them at risk in the last 24 hours
No, neither of these occurred in the last 24 hours
[Question G14 is asked only at Follow-up 1 and Follow-up 2]
G14. Did the client and counselor come up with a Risk Reduction Plan during session 1? (Confirm this response with the information recorded on the Session 1 Activity Form)
Yes
No [If ‘no’ is selected here, then please skip the Risk Reduction Plan section (questions 75-80). Please note that the client’s questionnaire will then end on question 74]
Decline to answer
CMEP-RESPECT BASELINE DATA COLLECTION: Client-level Data
Form Approved. OMB Number: 0920-0895
Expiration Date: 08/31/2014
Public reporting burden of this collection of information is estimated to average 20 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 number. Send comments regarding the 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-D74, Atlanta, Georgia 30333; ATTN: PRA (0920-0895).
Thank you for agreeing to participate in this survey. This survey is about your attitudes and behaviors regarding sex and sexually transmitted diseases (STDs). Many of the questions are very personal. Your answers will be kept private. Please answer as honestly and openly as you can. Do not hesitate to ask if you need help figuring out dates or if you don’t understand a question. There are no right or wrong answers. Let’s get started.
[Questions 1- 9 (the Demographics section) are only asked at Baseline]
Demographics
The first set of questions asks you to provide some general information about yourself.
What year were you born? ___ ___ ___ ___
How old are you? ______ [Clients must be 18 years of age or older to participate in CMEP-RESPECT] [Ensure that the age matches the year of birth given in question 1]
In which state do you currently live? (Choose one)
Hawaii
Oregon
Massachusetts
New York
New Jersey
Connecticut
Other _________________
Decline to answer
Are you: (Choose one)
Hispanic or Latino
Not Hispanic or Latino
Don’t know
Decline to answer
What is your race? (Choose all that apply)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Don’t know
Decline to answer [If any of the first 4 are checked, do not select ‘decline to answer’]
What was your sex at birth? (Choose one)
How do you currently identify yourself? (Choose one)
Male
Female
Transgender – Male to female
Transgender – Female to male
Other (Specify if your gender is not one of the choices above): _________________
Decline to answer
Do you consider yourself to be: (Choose one)
Homosexual (Gay, lesbian, same gender loving, queer, etc.)
Bisexual (Sexually attracted to both men and women)
Heterosexual (Straight)
Questioning (Unsure of your sexual orientation or exploring your sexual orientation)
Other (Specify if you do not consider yourself to be one of the choices above): ___________________
Decline to answer
What is the highest level of education that you have completed? (Choose one)
No schooling completed Bachelor’s degree
8th grade or less Post-graduate (Master’s degree)
Some high school Post-graduate (Doctoral-level degree)
High school graduate/GED Decline to answer
Some college (including technical school or training)
HIV & STD Testing
Read this aloud to the client: The next set of questions is about your history with HIV and STD testing.
Have you ever been tested for HIV? (Choose one)
Yes
No [If the client’s response is ‘no’, skip to question 14]
Decline to answer
When was your last HIV test? (If you can’t remember then take your best guess) (Choose one)
0-3 months ago
4-12 months ago
More than 12 months (1 year) ago
Decline to answer
What was the result of your last HIV test? (Choose one)
Negative [If the client’s response is ‘negative’, skip to question 14]
Positive
Don’t know [If the client’s response is ‘don’t know’, skip to question 14]
Decline to answer [Skip to question 15]
When did you first test positive for HIV? ___ ___/___ ___ ___ ___ (If you do not remember the month or year, please provide your best estimate.) [The year must be 1985 or later and the month and year cannot be greater than the current month and year]
Decline to answer
In the last 3 months (90 days), has a health care provider told you that you have/had any of the following: (Choose all that apply)
Gonorrhea
Syphilis
Chlamydia
No, I have not been diagnosed with any of these STDs in the last 3 months [If any of the first 3 are checked, do not select this response]
Decline to answer [If any of the first 4 are checked, do not select ‘decline to answer’]
Drug Use
The next of set questions ask about your experience with drugs over the last 3 months (90 days).
In the last 3 months (90 days), have you injected drugs? (This includes illegal drugs and other substances such as silicone, botox, hormones, etc.) (Choose one)
Yes
No [If the client’s response is ‘no’, skip to question 17]
Decline to answer
In the last 3 months (90 days), when you injected drugs how often did you share needles, syringes or works with someone else? (That is, you let someone else use your needles, syringes or works, or you borrowed someone else’s needles, syringes or works to inject drugs.) (Choose one) [Skip this question if the client’s response to question 15 was ‘no’]
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
Sexual Risk Behaviors with Male Partners
The next series of questions will ask about sex you have had with MALE partners. These questions are only asking about anal sex you have had with your male partners. They are NOT asking about oral sex (giving/getting blow jobs or head).
Anal sex is when one partner puts their penis into the other partner’s anus (butt).
The next questions ask about anal sex you’ve had with your male partners over the last 3 months (90 days). Some of the questions will ask you to report numbers. If your answer is 0 (zero) please enter 0 in the space provided.
In the last 3 months (90 days), have you had anal sex with a male? (Choose one)
Yes
No [If the client’s response is ‘no’, skip to the Sexual Risk Behavior with Female Partners section and then proceed with question 35]
Decline to answer
In the last 3 months (90 days), how many male partners have you had anal sex with? (Choose one)
______# partners [If the client’s response is ‘0’ remind the client that they answered ‘yes’ in question 17 to having anal sex with a male in the last 3 months] [If the client reports 45 or more male partners, please ask the client to confirm that number]
Decline to answer
In the last 3 months (90 days), how many times have you had anal sex with your male partner(s)? (Choose one)
______# times [The number of times that the client has had anal sex with their male partner(s) in question 19 MUST BE greater than or equal to the number of male anal sex partners in question 18. If not, then ask the client to confirm their responses to questions 18 and 19.] [If the response is ‘0’, remind the client that they answered ‘yes’ in question 17 to having anal sex with a male in the last 3 months]
Decline to answer
Of the ____ times [State the number of times from question 19] that you had anal sex with your male partner(s) during the last 3 months, how many times did you use a condom? (Choose one)
______# times [If the response to question 20 is 0, skip questions 22,24,26,28,30,32,34] [If the response to question 20 equals the number in question 19, then skip 22,24,26,28,30,32,34] [The number of times that the client has had unprotected anal sex with their male partner(s) in question 20 MUST BE less than or equal to the number of times they had sex in question 19. If not, then ask the client to confirm their responses to questions 19 and 20.]
Decline to answer
In the last 3 months (90 days), when you had anal sex with your male partner(s) how often were you drunk or high on drugs? (Choose one)
Never [If the client’s response is ‘never’, skip to question 23]
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
In the last 3 months (90 days), when you had anal sex with your male partner(s) while high or drunk, how often did you use condoms? (Choose one) [Skip this question if the response to question 20 was ‘0’ or the number given in question 20 was equal to the number given in question 19]
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
The next questions ask about anal sex with your male primary/main and casual partners.
A primary/main partner is someone you live with, have a special emotional connection with, love, and/or call your boyfriend/girlfriend/husband/wife.
A casual partner is someone you have had sex with but do not consider to be a primary/main partner. A casual partner may be someone you have had sex with one time or many times.
Some of the questions in this section will ask you to report numbers. If your answer is 0 (zero) please enter 0 in the space provided.
In the last 3 months (90 days), how many of the _____ men [State the number of men from question 18] that you have had anal sex with were primary/main partners? (Choose one)
______# primary/main partners [This number MUST BE less than or equal to the number provided in question 18. If not, then tell client that the number of primary/main male partners must be less than or equal to the total number of male partners and ask them to confirm their answers to question 18 and question 23.] [If the client reports 10 or more primary/main partners, review the definition of primary/main partner with the client and ask them to confirm the number of primary/main partners.] [If the client’s response is ‘0’, skip to question 25.]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when having anal sex with your male primary/main partner(s)? (Choose one) [Skip this question if the response to question 20 was ‘0’ or the number given in question 20 was equal to the number given in question 19]
Never
Sometimes
All the time
Decline to answer
In the last 3 months (90 days), how many of the ______ men [State the number of men from question 18] that you have had anal sex with were casual partners? (Choose one)
______# casual partners [The number of primary/main partners in question 23 plus the number of casual partners in question 25 MUST EQUAL the total number of male partners given in response to question 18. If not, ask the client to confirm their responses to question 18, 23, and 25.] [If the client’s response is ‘0’, skip to question 27.]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when having anal sex with your male casual partner(s)? (Choose one) [Skip this question if the response to question 20 was ‘0’ or the number given in question 20 was equal to the number given in question 19]
Never [If question 20 is greater than 0, and question 24 is never, then question 24 can’t be ‘never’. If this occurs, tell the client that how often they use condoms with their male primary and casual partners must correspond to their condom use with their total male partners. Have the client review questions 20, 24 and 26]
Sometimes
All the time [If question 20 is less than question 19 (indicating that some sex events were unprotected), and question 24 is ‘all the time’ then question 26 can’t be ‘all the time’.]
Decline to answer
The next set of questions is about the characteristics of the male partners you’ve had anal sex with.
In the last 3 months (90 days), did you have anal sex with a male who you knew had an HIV status that was different than yours? (Choose one)
Yes
No [If the client’s response is ‘no’, skip to question 29]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had anal sex with your male partner(s) whose HIV status was different than yours? (Choose one) [Skip this question if the response to question 20 was ‘0’ or the number given in question 20 was equal to the number given in question 19]
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
In the last 3 months (90 days), did a male sex partner give you money, drugs, a place to stay, clothing or something else you needed in exchange for anal sex? (Choose one)
Yes
No [If the client’s response is ‘no’, skip to question 31]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had anal sex with your male partner(s) who gave you money, drugs, a place to stay, clothing or something else you needed in exchange for anal sex? (Choose one) [Skip this question if the response to question 20 was ‘0’ or the number given in question 20 was equal to the number given in question 19]
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
In the last 3 months (90 days), did you give a male sex partner money, drugs, a place to stay, clothing or something else they needed in exchange for anal sex? (Some common terms for these men could include ‘sex workers’, ‘prostitutes’,’ hustlers’, etc.) (Choose one)
Yes
No [If the client’s response is ‘no’, skip to question 33]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had anal sex with your male partner(s) who you gave money, drugs, a place to stay, clothing or something else they needed in exchange for anal sex? (Choose one) [Skip this question if the response to question 20 was ‘0’ or the number given in question 20 was equal to the number given in question 19]
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
In the last 3 months (90 days), did you have anal sex with a male who you knew was an injection drug user? (That is, they injected illegal drugs or other substances such as silicone, botox, hormones, etc.) (Choose one)
Yes
No [If the client’s response is ‘no’, skip to question 35]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had anal sex with your male partner(s) who injected drugs? (Choose one) [Skip this question if the response to question 20 was ‘0’ or the number given in question 20 was equal to the number given in question 19]
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
Sexual Risk Behaviors with Female Partners
The next series of questions will ask about sex you have had with FEMALE partners. These questions are only asking about anal or vaginal sex you have had with your female partners. They are NOT asking about oral sex (giving/getting blow jobs or head). Anal sex means putting your penis into someone’s anus (butt).
Vaginal sex means putting your penis in someone’s vagina.
The next questions ask about anal or vaginal sex you’ve had with your female partners over the last 3 months (90 days). Some of the questions will ask you to report numbers. If your answer is 0 (zero) please enter 0 in the space provided.
In the last 3 months (90 days), have you had anal OR vaginal sex with a female? (Choose one)
Yes
No [If the client’s response is ‘no’, skip to the Sexual Risk Behavior with Transgender Partners section and then proceed with question 53]
Decline to answer
In the last 3 months (90 days), how many female partners have you had anal OR vaginal sex with? (Choose one)
______# partners [If the response is ‘0’ remind the client that they answered ‘yes’ in question 35 to having anal or vaginal sex with a female in the last 3 months] [If the client reports 45 or more female anal/vaginal partners in the last 3 months, ask the client to confirm their response]
Decline to answer
In the last 3 months (90 days), how many times have you had anal OR vaginal sex with your female partner(s)?
______# times [The number of times that the client has had anal or vaginal sex with their female partner(s) in question 37 MUST BE greater than or equal to the number of female anal or vaginal sex partners in question 36. If not, then ask the client to confirm their responses to questions 36 and 37.] [If the response is ‘0’ remind the client that they answered ‘yes’ in question 35 to having anal or vaginal sex with a female in the last 3 months]
Decline to answer
Of the ____times [State number of times from question 57] you had anal OR vaginal sex with your female partner(s) during the last 3 months, how many times did you use a condom?
______# times If the response to question 38 is 0, skip questions 40,42,44,46,48,50,52] [If the response to question 37 equals the number in question 38, then skip 40,42,44,46,48,50,52] [The number of times that the client has had unprotected sex with their female partner(s) in question 38 MUST BE less than or equal to the number of times they had sex in question 37. If not, then ask the client to confirm their responses to questions 37 and 38]
Decline to answer
In the last 3 months (90 days), when you had anal OR vaginal sex with your female partner(s) how often were you drunk or high on drugs? (Choose one)
Never [If the client’s response is ‘never’, skip to question 41]
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
In the last 3 months (90 days), when you had anal OR vaginal sex with your female partner(s) while high or drunk, how often did you use condoms? (Choose one) [Skip this question if the response to question 38 was ‘0’ or the number given in question 38 was equal to the number given in question 37]
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
The next questions ask about anal or vaginal sex with your female primary/main and casual partners.
A primary/main partner is someone you live with, have a special emotional connection with, love, and/or call your boyfriend/girlfriend/husband/wife.
A casual partner is someone you have had sex with but do not consider to be a primary/main partner. A casual partner may be someone you have had sex with one time or many times.
Some of the questions in this section ask you to report numbers. If your answer is 0 (zero) please enter 0 in the space provided.
In the last 3 months (90 days), how many of the ____ women [State the number of women from question 36] that you have had anal OR vaginal sex with were primary/main partners? (Choose one)
______# primary/main partners [The number of primary/main female partners in question 36 MUST BE less than or equal to the total number of female partners in question 41. If not, then ask the client to confirm their responses to question 36 and question 41.] [If the client reports 10 or more primary/main partners, review the definition of primary/main partner with the respondent and ask them to confirm the number of primary/main partners.] [If the client’s response is ‘0’, skip to question 43.]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when having anal OR vaginal sex with your female primary/main partner(s)? (Choose one) [Skip this question if the response to question 38 was ‘0’ or the number given in question 38 was equal to the number given in question 37]
Never
Sometimes
All the time
Decline to answer
In the last 3 months (90 days), how many of the ____ women [State the number of women from question 36] that you have had anal OR vaginal sex with were casual partners? (Choose one)
______# casual partners (If 0, enter 0) [The number of primary/main female partners in question 41 plus the number of casual female partners in question 43 MUST EQUAL the total number of female partners given in response to question 36. If not, ask the client to confirm their responses to question 36, 41 and 43.] [If the client’s response is ‘0’, skip to question 45]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when having anal OR vaginal sex with your female casual partner(s)? (Choose one) [Skip this question if the response to question 38 was ‘0’ or the number given in question 38 was equal to the number given in question 37]
Never [If question 38 is greater than 0, and question 42 is never, then question 44 can’t be ‘never’. If this occurs, tell the client that how often they use condoms with their female primary and casual partners must correspond to their condom use with their total female partners. Have the client review questions 38, 42 and 44]
Sometimes
All the time [If question 38 < question 37 (indicating that some sex events were unprotected), and question 42 is ‘all the time’ then question 44 can’t be ‘all the time’.]
Decline to answer
The next set of questions is about the characteristics of the female partners you’ve had anal or vaginal sex with.
In the last 3 months (90 days), did you have anal OR vaginal sex with a female who you knew had an HIV status that was different than yours? (Choose one)
Yes
No [If the client’s response is ‘no’, skip to question 47]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had anal OR vaginal sex with your female partner(s) whose HIV status was different than yours? (Choose one) [Skip this question if the response to question 38 was ‘0’ or the number given in question 38 was equal to the number given in question 37]
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
In the last 3 months (90 days), did a female sex partner give you money, drugs, a place to stay, clothing or something else you needed in exchange for anal OR vaginal sex? (Choose one)
Yes
No [If the client’s response is ‘no’, skip to question 49]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had anal OR vaginal sex with your female partner(s) that gave you money, drugs, a place to stay, clothing or something else you needed in exchange for anal OR vaginal sex? (Choose one) [Skip this question if the response to question 38 was ‘0’ or the number given in question 38 was equal to the number given in question 37]
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
In the last 3 months (90 days), did you give a female sex partner money, drugs, a place to stay, clothing or something else they needed in exchange for anal OR vaginal sex? (Choose one) (Some common terms for these men could include ‘sex workers’, ‘prostitutes’,’ hustlers’, etc.)
Yes
No [If the client’s response is ‘no’, skip to question 51]
Decline to answer
In the last 3 months (90 days), how often did you use condoms with your female partner(s) that you gave money, drugs, a place to stay, clothing or something else they needed in exchange for anal OR vaginal sex? (Choose one) [Skip this question if the response to question 38 was ‘0’ or the number given in question 38 was equal to the number given in question 37]
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
In the last 3 months (90 days), did you have anal OR vaginal sex with a female who you knew was an injection drug user? (Choose one) (That is, they injected illegal drugs or other substances such as silicone, botox, hormones, etc.)
Yes
No [If the client’s response is ‘no’, skip to question 53]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had anal OR vaginal sex with your female partner(s) who injected drugs? (Choose one) [Skip this question if the response to question 38 was ‘0’ or the number given in question 38 was equal to the number given in question 37]
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
Sexual Risk Behaviors with Transgender Partners
The next series of questions will ask about sex you have had with TRANSGENDER partners. These questions are only asking about anal or vaginal sex you have had with your transgender partners. They are NOT asking about oral sex (giving/getting blow jobs or head).
Anal sex is when one partner puts their penis into the other partner’s anus (butt).
Vaginal sex means putting your penis in someone’s vagina.
The next questions ask about anal or vaginal sex you’ve had with your transgender partners over the last 3 months (90 days). Some of the questions will ask you to report numbers. If your answer is 0 (zero) please enter 0 in the space provided.
In the last 3 months (90 days), have you had anal OR vaginal sex with a transgender partner? (Choose one)
Yes
No [If the client’s response is ‘no’ and this is Baseline or Follow-up 1, skip to question 72A. If the client’s response is ‘no’ and this is Follow-up 2, skip to 71.]
Decline to answer
In the last 3 months (90 days), how many transgender sex partners have you had anal OR vaginal sex with? (Choose one)
______# partners [If the response is ‘0’ remind the client that they answered yes in question 53 to having anal or vaginal sex with a transgender in the last 3 months] [If the client reports 45 or more transgender partners in the last 3 months, ask the client to confirm their response]
Decline to answer
In the last 3 months (90 days), how many times have you had anal OR vaginal sex with your transgender partner(s)? (Choose one)
______# times [The number of times that the client has had anal or vaginal sex with their transgender partner(s) in question 55 MUST BE greater than or equal to the number of transgender anal or vaginal sex partners in question 54. If not, then ask the client to confirm their responses to questions 54 and 55.] [If the response is ‘0’ remind the client that they answered ‘yes’ in question 53 to having anal or vaginal sex with a transgender in the last 3 months]
Decline to answer
Of the ____ times [State the number of times from question 55] you had anal OR vaginal sex with your transgender partner(s) during the last 3 months, how often did you use a condom?
______# times If the response to question 56 is 0, skip questions 58,60,62,64,66,68,70] [If the response to question 56 equals the number in question 55, then skip 58,60,62,64,66,68,70] [The number of times that the client has had unprotected anal sex with their male partner(s) in question 56 MUST BE less than or equal to the number of times they had sex in question 55. If not, then ask the client to confirm their responses to questions 55 and 56.]
Decline to answer
In the last 3 months (90 days), when you had anal OR vaginal sex with your transgender partner(s) how often were you drunk or high on drugs? (Choose one)
Never [If the client’s response is ‘no’, skip to question 59]
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
In the last 3 months (90 days), when you had anal OR vaginal sex with transgender partner(s) while high or drunk, how often did you use condoms? (Choose one) [Skip this question if the response to question 56 was ‘0’ or the number given in question 56 was equal to the number given in question 55]
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
The next questions ask about anal or vaginal sex with your transgender primary/main and casual partners.
A primary/main partner is someone you live with, have a special emotional connection with, love, and/or call your boyfriend/girlfriend/husband/wife.
A casual partner is someone you have had sex with but do not consider to be a primary/main partner. A casual partner may be someone you have had sex with one time or many times.
Some of the questions in this section ask you to report numbers. If your answer is 0 (zero) please enter 0 in the space provided.
In the last 3 months (90 days), how many of the ____ transgender partners [State number of transgender partners from question 54] transgender partners that you have had anal OR vaginal sex with were primary/main partners? (Choose one)
______# primary/main partners [The number of primary/main transgender partners in question 59 MUST BE less than or equal to the total number of transgender partners in question 54. If not, then ask the client to confirm their responses to question 54 and question 59.] [If the client reports 10 or more primary/main transgender partners, review the definition of primary/main partner with the respondent and ask them to confirm the number of primary/main partners.] [If the client’s response is ‘0’, skip to question 61.]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when having anal OR vaginal sex with your transgender primary/main partner(s)? (Choose one) [Skip this question if the response to question 56 was ‘0’ or the number given in question 56 was equal to the number given in question 55]
Never
Sometimes
All the time
Decline to answer
In the last 3 months (90 days), how many of the ____ transgender partners [State the number of transgender partners from question 54] that you have had anal OR vaginal sex with were casual partners? (Choose one)
______# casual partners (If 0, enter 0) [The number of primary/main transgender partners in question 59 plus the number of casual transgender partners in question 61 MUST EQUAL the total number of transgender partners given in response to question 54. If not, ask the client to confirm their responses to question 54, 59, and 61.] [If the client’s response is ‘0’, skip to question 63]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when having anal OR vaginal sex with your transgender casual partner(s)? (Choose one) [Skip this question if the response to question 56 was ‘0’ or the number given in question 56 was equal to the number given in question 55]
Never [If the response to question 56 is greater than 0, and question 60 is ‘never’, then question 62 can’t be ‘never’. If this occurs, tell the client that how often they use condoms with their transgender primary and casual partners must correspond to their condom use with their total transgender partners. Have the client review questions 56, 60, and 62]
Sometimes
All the time [If question 56 < question 55 (indicating that some sex events were unprotected), and question 60 is ‘all the time’ then question 62 can’t be ‘all the time’.]
Decline to answer
The next set of questions is about the characteristics of the transgender partners you’ve had anal or vaginal sex with.
In the last 3 months (90 days), did you have anal OR vaginal sex with a transgender partner who you knew had an HIV status that was different than yours? (Choose one)
Yes
No [If the client’s response is ‘no’, skip to question 65]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had anal OR vaginal sex with your transgender partner(s) whose HIV status was different than yours? (Choose one) [Skip this question if the response to question 56 was ‘0’ or the number given in question 56 was equal to the number given in question 55]
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
In the last 3 months (90 days), did a transgender sex partner give you money, drugs, a place to stay, clothing or something else you needed in exchange for anal OR vaginal sex? (Choose one)
Yes
No [If the client’s response is ‘no’, skip to question 67]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had anal OR vaginal sex with your transgender partner(s) that gave you money, drugs, a place to stay, clothing or something else you needed in exchange for anal OR vaginal sex? (Choose one) [Skip this question if the response to question 56 was ‘0’ or the number given in question 56 was equal to the number given in question 55]
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
In the last 3 months (90 days), did you give a transgender sex partner money, drugs, a place to stay, clothing or something else they needed in exchange for anal OR vaginal sex? (Some common terms for these individuals could include ‘sex workers’, ‘prostitutes’, etc.) (Choose one)
Yes
No [If the client’s response is ‘no’, skip to question 69]
Decline to answer
In the last 3 months (90 days), how often did you use condoms with transgender partner(s) that you gave money, drugs, a place to stay, clothing or something else they needed in exchange for anal OR vaginal sex? (Choose one) [Skip this question if the response to question 56 was ‘0’ or the number given in question 56 was equal to the number given in question 55]
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
In the last 3 months (90 days), did you have anal OR vaginal sex a transgender partner who you knew was an injection drug user? (That is, they injected illegal drugs or other substances such as silicone, botox, insulin, hormones, etc.) (Choose one)
Yes
No [If the client’s response is ‘no’, and you are completing Follow-up 2, skip to 71. If the client’s response is ‘no’, and you are completing Baseline or Follow-up 1, skip to the Correct Condom Use section and proceed with question 72A]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had anal OR vaginal sex with your transgender partner(s) who injected drugs? (Choose one) [Skip this question if the response to question 56 was ‘0’ or the number given in question 56 was equal to the number given in question 55]
Never
Less than half the time
Half the time
More than half the time
All the time
Decline to answer
[Question 71 is only asked at Follow-up 2. If you are completing Baseline or Follow-up 1, skip the Total Number of Partners section and proceed to the Correct Condom Use section and question 72A.]
Total Number of Partners
[This section is only asked at Follow-up 2.]
The next section will ask you about sex with all of your partners (male, female, and transgender) in the last 9 months (270 days). This question is only asking about anal or vaginal sex you have had with your partners. They are NOT asking about oral sex (giving/getting blow jobs or head).
71. In the last 9 months (270 days), how many individuals (male, female, and transgender) have you had anal or vaginal sex with?
______# of partners
Correct Condom Use
This section will ask you about your experience using condoms.
72A. Did you use a male condom the last time you had vaginal or anal sex? (Choose one)
Yes
No
Decline to answer
72B. Do you plan to use a male condom the next time you have vaginal or anal sex? (Choose one)
Yes
No
Decline to answer
72C. In the next 3 months, do you plan on using a male condom every time you have vaginal or anal sex? (Choose one)
Yes
No
Decline to answer
Perceived HIV Risk
The next set of questions is about how likely you think it is that you will get HIV/STDs or give HIV/STDs to someone else.
What do you think is your chance of getting HIV/AIDS in the future if you do not use condoms every time you have sex? (Choose one) [Skip this question if the client is HIV-positive, as indicated in question 12]
No chance
Unlikely
Likely
Certain to happen
Decline to answer
What do you think is your chance of getting a STD in the future if you do not use condoms every time you have sex? (Choose one)
No chance
Unlikely
Likely
Certain to happen
Decline to answer
[If you are completing Follow-up 1 or Follow-up 2 and the client’s response to question G14 was ‘no’, you do not need to ask the questions in the Risk Reduction Plan section (questions 75-80) and this will be the end of the questionnaire. Thank the client for their participation.]
Risk Reduction Plan
Think back to your RESPECT session and any risk reduction plan that you made with your RESPECT counselor/facilitator. The next set of questions is about this plan.
Did you try to follow the Risk Reduction Plan that you developed with your RESPECT counselor? (Choose one)
Yes
No [If the client’s response is ‘no’, skip to question 79]
Decline to answer
In your opinion, were you successful in doing this plan? (Choose one)
Yes
No [If the client’s response is ‘no’, skip to question 78]
Decline to answer
In your opinion, how likely is it that by doing this plan your risk for getting HIV or a STD was reduced? (Choose one) [If the client’s response to question 76 was ‘yes’, then after this question is answered, skip to question 80 which will be the last question of the interview]
Very unlikely
Unlikely
Likely
Very likely
Decline to answer
In your opinion, if you had successfully done this plan, how likely is it that this would have reduced your risk for getting HIV or a STD? (Choose one) [This question should only be asked if question 76 was ‘no’.]
Very unlikely
Unlikely
Likely
Very likely
Decline to answer
In your opinion, what was the main reason for not trying or not succeeding with this plan? (Choose one) [This question should only be asked if question 75 or 76 was ‘no’]
I forgot about it
I tried something else
It was too difficult
It did not seem important
It would not have reduced my risk
I was concerned about my partner’s reaction
My partner did not want to do it
I felt I needed skills, practice or experience to follow through with the plan
Some other reason (Specify the reason)
Decline to answer
Which of these things made doing this plan difficult over the last 90 days? (Choose all that apply)
I felt I needed more skills to follow through with the plan
It was hard to remember that I had made the plan
I needed to change the plan to make it work
It was uncomfortable for me
I needed someone to talk to about my plan
I had concerns about my partner(s) reactions
My partner(s) were not cooperative or supportive
I did not have any difficulty with the plan
I had another barrier (Specify)
Decline to answer
Thank you! You have now finished the questionnaire. Please ask for a staff member.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Dii7 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-27 |