Form Approved
OMB No. 0920-0896
Exp. Date: XX/XX/XXXX
“Community-based Organization (CBO) Monitoring and Evaluation Project of WILLOW (CMEP-WILLOW)”
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 (0920-0896).
CMEP-WILLOW 90-DAY FOLLOW-UP DATA COLLECTION: General Information
(to be completed by staff)
The following section will be completed by CMEP-WILLOW staff.
G1. Client ID: ___ ___ ___ ___ [QDS QA Check: This number cannot be longer than 4 digits]
G2. Staff ID: ____________
G3. Data collection date: __ __/__ __/__ __ __ __ [QDS Instructions: drop-down menu]
(MM/DD/YYYY)
G4. Data collection site: __________________
G5. Data administered by: (Choose one)
Client
Provider (in-person)
Provider (on phone)
G6. Data collection method: (Choose one)
Laptop
Handheld device
Hard copy
G7. In the past 3 months, have you… (Choose all that apply)
Participated in a face-to-face group discussion about HIV prevention, HIV testing or safer sex
practices
Participated in an on-line discussion about HIV prevention, HIV testing, or safer sex practices
Received condoms or a safe sex kit
Received HIV Case Management services
Received Partner Services
Received written information about HIV/AIDS or STDs
Received other HIV prevention services (if yes, specify ____________________)
Has not participated in discussions or received materials related HIV/AIDS or STDs
Decline to answer
G8. In the past 3 months, has the client participated in any HIV prevention interventions (e.g., CDC effective behavioral interventions [EBIs])? (Choose one)
Yes
No [QDS Skip: Skip to Q1]
Decline to answer
G9. If yes, which one(s)? (Choose all that apply) (Note: These interventions may be called a different name at each agency)
Clear Safe in the City
Connect Safety Counts
Focus on Youth + IMPACT SHIELD
Healthy Relationships SIHLE
Holistic Health Recovery Program SISTA
MIP Sister to Sister
Partnership for Health Street Smart
Popular Opinion Leader Together Learning Choices
Project Start VOICES/VOCES
PROMISE WILLOW
RAPP Other (specify): ___________________
RESPECT Decline to answer
CMEP-WILLOW DATA COLLECTION: Client-level Data
(to be completed by client)
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 don’t understand a question or need help figuring out dates. There are no right or wrong answers. Let’s get started.
Demographics
The first set of questions asks you to provide some general information about yourself.
*(G123) What was your sex at birth? (This is the biological sex on your birth certificate.) (Choose one)
Male
Female
Decline to answer
*(G124) How do you currently identify yourself? (Choose one)
Male
Female
Transgender – Male to female [QDS QA Check: If selected, include section about female partners]
Transgender – Female to male
Other (Specify if your gender is not one of the choices above): _________________
Decline to answer
What is your current marital status? (Choose one)
Never married
Married
Separated
Divorced
Widowed
Decline to answer
Are you currently …? (Choose all that apply)
Employed for wages
Self-employed
Unemployed
Receiving unemployment benefits
Receiving public financial assistance (e.g., food stamps)
Receiving social security and/or disability
A homemaker
A student
Retired
Unable to work
Decline to answer
HIV & STD Testing, Medical Care, and Other HIV Services
The next set of questions is about your history with HIV and STD testing, medical care, and other HIV services.
*(G208) Have you seen a primary health care provider (doctor, nurse, etc.) for HIV-related care in the last 6 months? (Choose one)
Yes
No
Decline to answer
Have you been prescribed (anti-retroviral) medication for your HIV? (Choose one)
Yes
No [QDS Skip: If no, then skip to Q8]
Decline to answer
Have you been taking these HIV medications as directed over the last 6 months? (Choose one)
Yes
No
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 a STD in the last 3 months [QDS QA Check: If any of the first 3 are checked, this response should not be enabled]
Decline to answer [QDS QA Check: If any of the first 4 are checked, ‘Decline to Answer’ should not be enabled]
Are you pregnant? (Choose one) [QDS QA Check: Do not ask if transgender male to female]
Yes
No [QDS Skip: Skip to Q11]
Don’t know [QDS Skip: Skip to Q11]
Decline to answer
Are you in prenatal care? (Choose one) [QDS QA Check: Do not ask if transgender male to female]
Yes
No
Decline to answer
Drug Use and Living Situation
The next of set questions are about your experience with drugs and your living situation.
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 [QDS Skip: Skip to Q13]
Decline to answer
In the last 3 months (90 days), how often did you share needles, syringes, or works? (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)
Never
Sometimes
Always
Decline to answer
In the last 3 months (90 days), were you homeless at any time? (That is, you slept in a shelter for homeless people, on the streets, in a car, or another place not intended for sleeping. In other words, you didn’t have a permanent address.) (Choose one)
Yes
No
Decline to answer
In the last 3 months (90 days), were you in jail or prison for more than 24 hours? (Choose one)
Yes
No
Decline to answer
Sexual Risk Behaviors with Male Partners
The next series of questions will ask about sex you have had with a man. These questions are only asking about vaginal or anal sex you have had with a man. They are NOT asking about oral sex (giving/getting blow jobs or head).
Vaginal sex is when a man puts his penis in your vagina (hole in front). Anal sex is when a man puts his penis into your anus (butt, hole in back). Condom use refers to the use of a male condom, unless a female condom is mentioned.
Sex with Men in the Last 3 months (90 days)
The next questions ask about vaginal or anal sex you’ve had with men over the last 3 months (90 days). Some of the questions will ask you to report numbers. If your answer is none, please enter 0 (zero).
In the last 3 months (90 days), have you had vaginal or anal sex with a man? (Choose one)
Yes
No [QDS Skip: If no, then only ask Q22-Q26, Q85-87, Q89-155]
Decline to answer
In the last 3 months (90 days), how many men have you had vaginal or anal sex with? (Choose one)
______# partners [QDS QA Check: If response = 0 prompt respondent that they answered Yes in Q15 to having vaginal or anal sex with a male in the last 3 months; QDS QA Check: If Q16 ≥ 46 ask the respondent to confirm]
Decline to answer
In the last 3 months (90 days), how many times have you had vaginal or anal sex with a man? (Choose one)
______# times [QDS QA Check: Q17 ≥ Q16. If no, then tell respondent that the number of times must be greater than or equal to the number of partners and have them verify Q16 and Q17; QDS QA Check: If response = 0 prompt respondent that they answered Yes in Q15 to having anal sex with a male in the last 3 months]
Decline to answer
Of the (#) [QDS Instructions: Populate with Q17 # response] times you had vaginal or anal sex with a man during the last 3 months, how many times did you use a condom? (Choose one)
______ # times [QDS QA Check: Q18 ≤ Q17. If no, then tell respondent that the number of times they used a condom must be less than or equal to the number of times they had sex and have them verify Q17 and Q18; QDS QA Skip: If Q18 = Q17 or Q18 = 0, skip (do not ask) Qs 21, 28, 30, 32, 34, 36, 38, 40, 42, 44, 46, 48, 83, or 84]
Decline to answer
In the last 3 months (90 days), when you had vaginal or anal sex with a man, how often were you drunk or high on drugs? (Choose one)
Never [QDS Skip: Skip to Q22]
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 vaginal or anal sex with a man while high or drunk, which were you using? (Choose all that apply)
Amphetamines, meth, speed, crystal, ice or crank Crack
Heroin (injected, smoked, or snorted) Poppers (Amyl nitrate)
Painkillers (including Oxycontin, Percocet) Downers (Valium, Ativan, Xanax)
Club drugs such as GHB (G), Ketamine (K) Ecstasy (E)
Marijuana (pot) Hallucinogens such as LSD (acid)
Cocaine (smoked, snorted, or injected) Alcohol
Other: __________________
Decline to answer [QDS QA Check: If any of the first 13 are checked, ‘Decline to Answer’ should not be enabled]
In the last 3 months (90 days), when you had vaginal or anal sex with a man while high or drunk, how often did you use condoms? (Choose one)
Never
Sometimes
Always
Decline to answer
The next questions ask about vaginal and anal sex with your MALE primary/main and casual sexual partners.
A primary/main partner is someone you have a special emotional connection with, live with, love, and/or call your boyfriend/husband.
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.
Do you currently have a primary or main male partner? (Choose one)
Yes
No [QDS QA Skip: Skip to Q27]
Decline to answer
How long have you been with your current primary or main male partner? (Choose one)
Less than 6 months
6 months to 1 year
1 to 5 years
Longer than 5 years
Decline to answer
Are you living with your primary or main male partner? (Choose one)
Yes
No
Decline to answer
Are you financially dependent on your primary or main male partner? (Choose one)
Yes
No
Decline to answer
Is your current primary or main male partner HIV-positive? (Choose one)
Yes
No
Don’t know
Decline to answer
In the last 3 months (90 days), how many of the (#) [QDS Instructions: Populate with Q16 # response] men that you have had vaginal or anal sex with were primary/main partners? (Choose one)
______# primary/main partners [QDS QA Check: Q27 must be less than or equal to Q16. If not, then tell client that the number of primary/main male partners must be less or equal to the total number of male and ask them to confirm their answers to Q16 and Q27; QDS QA check If Q27 ≥ 10, refer respondent to the definition of primary/main partner and ask them to confirm the number of primary/main partners; QDS QA Check: If response = 0 skip to Q29]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when having vaginal or anal sex with your male primary/main partner(s)? (Choose one)
Never
Sometimes
Always
Decline to answer
In the last 3 months (90 days), how many of the (#) [QDS Instructions: Populate with Q16 # response] men that you have had vaginal or anal sex with were casual partners? (Choose one)
______# casual partners (If 0, enter 0) [QDS QA Check: Q27 + Q29 = Q16. If no, tell client that the number of primary/main partners plus the number of casual partners must equal the total number of male partners. Ask client to confirm Q16, 27, and 29; QDS QA Check: If response = 0 skip to Q31]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when having vaginal or anal sex with your male casual partner(s)? (Choose one)
Never
Sometimes
Always
Decline to answer
The next set of questions is about the characteristics of the male partners you’ve had vaginal or anal sex with. Some of the questions will ask you to report numbers. If your answer is none, please enter 0 (zero) in the space provided.
In the last 3 months (90 days), did you have vaginal or anal sex with a male who had an HIV status that was unknown to you? (Choose one)
Yes
No [QDS Skip: Skip to Q33]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had a vaginal or anal sex with your male partner(s) whose HIV status you didn’t or don’t know? (Choose one)
Never
Sometimes
Always
Decline to answer
In the last 3 months (90 days), did you have vaginal or anal sex with a male who was HIV-negative? (Choose one)
Yes
No [QDS Skip: Skip to Q35]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex with your male partner(s) who was HIV-negative? (Choose one)
Never
Sometimes
Always
Decline to answer
In the last 3 months (90 days), did you have vaginal or anal sex with a male only one time? (That is, a one-night stand.) (Choose one)
Yes
No [QDS Skip: Skip to Q37]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex with your male partner(s) who you had vaginal or anal sex with only one time? (Choose one)
Never
Sometimes
Always
Decline to answer
In the last 3 months (90 days), did you have vaginal or anal sex with a male who was a stranger or anonymous? (That is, you do not know their name and you have no way of contacting them.) (Choose one)
Yes
No [QDS Skip: Skip to Q39]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex with your anonymous male partner(s)? (Choose one)
Never
Sometimes
Always
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 vaginal or anal sex? (Choose one)
Yes
No [QDS Skip: Skip to Q41]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex with a man who gave you money, drugs, a place to stay, clothing, or something else you needed in exchange for vaginal or anal sex? (Choose one)
Never
Sometimes
Always
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 vaginal or anal sex? (Choose one)
Yes
No [QDS Skip: Skip to Q43]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had vaginal or 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 vaginal or anal sex? (Choose one)
Never
Sometimes
Always
Decline to answer
In the last 3 months (90 days), did you have vaginal or 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 [QDS Skip: Skip to Q45]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex with your male partner(s) who injected drugs? (Choose one)
Never
Sometimes
Always
Decline to answer
In the last 3 months (90 days), did you have vaginal or anal sex with a male who you knew had spent more than 24 hours in jail?
Yes
No [QDS Skip: Skip to Q47]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex with your male partner(s) who had spent more than 24 hours in jail? (Choose one)
Never
Sometimes
Always
Decline to answer
In the last 3 months (90 days), did you have vaginal or anal sex with a male who had a STD like syphilis (syphpox), Chlamydia, or gonorrhea (clap)? (Choose one)
Yes
No [QDS Skip: Skip to Q83 unless Male to Female Transgender, then skip to Q49]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex with your male partner(s) who had syphilis, Chlamydia, or gonorrhea? (Choose one)
Never
Sometimes
Always
Decline to answer
Sexual Risk Behaviors with Female Partners
[QDS Check: This section is only for Male to Female Transgender]
The next series of questions will ask about sex you have had with a woman. These questions are only asking about vaginal or anal sex you have had with a woman. They are NOT asking about oral sex (giving/getting blow jobs or head).
Vaginal sex is when you put a penis in a vagina (hole in front). Anal sex is when you puts a penis into an anus (butt, hole in back). Condom use refers to the use of a male condom, unless a female condom is mentioned.
Sex with Women in the Last 3 months (90 days)
The next questions ask about vaginal or anal sex you’ve had with women over the last 3 months (90 days). Some of the questions will ask you to report numbers. If your answer is none, please enter 0 (zero).
In the last 3 months (90 days), have you had vaginal or anal sex with a woman? (Choose one)
Yes
No [QDS Skip: If no, then only ask Q56-Q60, Q85-87, Q89-155]
Decline to answer
In the last 3 months (90 days), how many women have you had vaginal or anal sex with? (Choose one)
______# partners [QDS QA Check: If response = 0 prompt respondent that they answered Yes in Q49 to having vaginal or anal sex with a female in the last 3 months; QDS QA Check: If Q50 ≥ Q61 ask the respondent to confirm]
Decline to answer
In the last 3 months (90 days), how many times have you had vaginal or anal sex with a woman? (Choose one)
______# times [QDS QA Check: Q51 ≥ Q50. If no, then tell respondent that the number of times must be greater than or equal to the number of partners and have them verify Q50 and Q51; QDS QA Check: If response = 0 prompt respondent that they answered Yes in Q49 to having anal sex with a female in the last 3 months]
Decline to answer
Of the (#) [QDS Instructions: Populate with Q51 # response] times you had vaginal or anal sex with a woman during the last 3 months, how many times did you use a condom? (Choose one)
______ # times [QDS QA Check: Q52 ≤ Q51. If no, then tell respondent that the number of times they used a condom must be less than or equal to the number of times they had sex and have them verify Q51 and Q52; QDS QA Skip: If Q52 = Q51 or Q52 = 0, skip (do not ask) Qs 55, 62, 64, 66, 68, 70, 72, 74, 76, 78, 80, 82, 83, or 84]
Decline to answer
In the last 3 months (90 days), when you had vaginal or anal sex with a woman, how often were you drunk or high on drugs? (Choose one)
Never [QDS Skip: Skip to Q56]
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 vaginal or anal sex with a woman while high or drunk, which were you using? (Choose all that apply)
Amphetamines, meth, speed, crystal, ice or crank Crack
Heroin (injected, smoked, or snorted) Poppers (Amyl nitrate)
Painkillers (including Oxycontin, Percocet) Downers (Valium, Ativan, Xanax)
Club drugs such as GHB (G), Ketamine (K) Ecstasy (E)
Marijuana (pot) Hallucinogens such as LSD (acid)
Cocaine (smoked, snorted, or injected) Alcohol
Other: __________________
Decline to answer [QDS QA Check: If any of the first 13 are checked, ‘Decline to Answer’ should not be enabled]
In the last 3 months (90 days), when you had vaginal or anal sex with a woman while high or drunk, how often did you use condoms? (Choose one)
Never
Sometimes
Always
Decline to answer
The next questions ask about vaginal and anal sex with your FEMALE primary/main and casual sexual partners.
A primary/main partner is someone you have a special emotional connection with, live with, love, and/or call your girlfriend/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.
Do you currently have a primary or main female partner? (Choose one)
Yes
No [QDS QA Skip: Skip to Q61]
Decline to answer
How long have you been with your current primary or main female partner? (Choose one)
Less than 6 months
6 months to 1 year
1 to 5 years
Longer than 5 years
Decline to answer
Are you living with your primary or main female partner? (Choose one)
Yes
No
Decline to answer
Are you financially dependent on your primary or main female partner? (Choose one)
Yes
No
Decline to answer
Is your current primary or main female partner HIV-positive? (Choose one)
Yes
No
Don’t know
Decline to answer
In the last 3 months (90 days), how many of the (#) [QDS Instructions: Populate with Q50 # response] women that you have had vaginal or anal sex with were primary/main partners? (Choose one)
______# primary/main partners [QDS QA Check: Q61 must be less than or equal to Q50. If not, then tell client that the number of primary/main female partners must be less or equal to the total number of females and ask them to confirm their answers to Q50 and Q61; QDS QA check If Q61 ≥ 10, refer respondent to the definition of primary/main partner and ask them to confirm the number of primary/main partners; QDS QA Check: If response = 0 skip to Q63]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when having vaginal or anal sex with your female primary/main partner(s)? (Choose one)
Never
Sometimes
Always
Decline to answer
In the last 3 months (90 days), how many of the (#) [QDS Instructions: Populate with Q50 # response] women that you have had vaginal or anal sex with were casual partners? (Choose one)
______# casual partners (If 0, enter 0) [QDS QA Check: Q61 + Q63 = Q50. If no, tell client that the number of primary/main partners plus the number of casual partners must equal the total number of female partnersfemale partners. Ask client to confirm Q50, Q61, and Q63; QDS QA Check: If response = 0 skip to Q65]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when having vaginal or anal sex with your female casual partner(s)? (Choose one)
Never
Sometimes
Always
Decline to answer
The next set of questions is about the characteristics of the female partners you’ve had vaginal or anal sex with. Some of the questions will ask you to report numbers. If your answer is none, please enter 0 (zero) in the space provided.
In the last 3 months (90 days), did you have vaginal or anal sex with a female who had an HIV status that was unknown to you? (Choose one)
Yes
No [QDS Skip: Skip to Q67]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had vaginalhad vaginal or anal sex with your female partner(s) whose HIV status you didn’t or don’t know? (Choose one)
Never
Sometimes
Always
Decline to answer
In the last 3 months (90 days), did you have vaginal or anal sex with a female who was HIV-negative? (Choose one)
Yes
No [QDS Skip: Skip to Q69]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex with your female partner(s) who was HIV-negative? (Choose one)
Never
Sometimes
Always
Decline to answer
In the last 3 months (90 days), did you have vaginal or anal sex with a female only one time? (That is, a one-night stand.) (Choose one)
Yes
No [QDS Skip: Skip to Q71]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex with your female partner(s) who you had vaginal or anal sex with only one time? (Choose one)
Never
Sometimes
Always
Decline to answer
In the last 3 months (90 days), did you have vaginal or anal sex with a female who was a stranger or anonymous? (That is, you do not know their name and you have no way of contacting them.) (Choose one)
Yes
No [QDS Skip: Skip to Q73]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex with your anonymous female partner(s)? (Choose one)
Never
Sometimes
Always
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 vaginal or anal sex? (Choose one)
Yes
No [QDS Skip: Skip to Q75]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex with a female who gave you money, drugs, a place to stay, clothing, or something else you needed in exchange for vaginal or anal sex? (Choose one)
Never
Sometimes
Always
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 vaginal or anal sex? (Choose one)
Yes
No [QDS Skip: Skip to Q77]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex with your female partner(s) who you gave money, drugs, a place to stay, clothing, or something else they needed in exchange for vaginal or anal sex? (Choose one)
Never
Sometimes
Always
Decline to answer
In the last 3 months (90 days), did you have vaginal or anal sex with a female 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 [QDS Skip: Skip to Q79]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex with your female partner(s) who injected drugs? (Choose one)
Never
Sometimes
Always
Decline to answer
In the last 3 months (90 days), did you have vaginal or anal sex with a female who you knew had spent more than 24 hours in jail?
Yes
No [QDS Skip: Skip to Q81]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex with your female partner(s) who had spent more than 24 hours in jail? (Choose one)
Never
Sometimes
Always
Decline to answer
In the last 3 months (90 days), did you have vaginal or anal sex with a female who had a STD like syphilis (syphpox), Chlamydia, or gonorrhea (clap)? (Choose one)
Yes
No [QDS Skip: Skip to Q83]
Decline to answer
In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex with your female partner(s) who had syphilis, Chlamydia, or gonorrhea? (Choose one)
Never
Sometimes
Always
Decline to answer
Condom Use
This section will ask you about your experience using condoms when you were having vaginal or anal sex.
In the last 3 months (90 days), how often did the male condom break or slip off during sex while your partner was pulling out? (Choose one)
Never
Sometimes
All the time
Don’t know
Decline to answer
In the last 3 months (90 days), how often did you use the male condom after you had started having sex or take the condom off before you had finished having sex? (Choose one)
Never
Sometimes
All the time
Don’t know
Decline to answer
Did you use a male condom the last time you had vaginal or anal sex? (Choose one)
Yes
No
Decline to answer
Do you plan to use a male condom the next time you have vaginal or anal sex? (Choose one)
Yes
No
Decline to answer
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
In the last 3 months, did you attempt to use a female condom? (Choose one)
Yes
No
I don’t know what a female condom is
Decline to answer
In the next 3 months, do you plan on using a female condom? (Choose one)
Yes
No
Decline to answer
Attitudes and Beliefs Toward Condom Use
The following statements are about your attitudes toward using male condoms.
My partner would get mad if I said we had to use a condom. (Choose one)
Yes
No
Decline to Answer
My partner would think I was having sex with another person if I said we had to use a condom. (Choose one)
Yes
No
Decline to Answer
Condoms ruin the mood. (Choose one)
Yes
No
Decline to Answer
Sex doesn’t feel as good when you use a condom. (Choose one)
Yes
No
Decline to Answer
Sex with male condoms doesn’t feel natural. (Choose one)
Yes
No
Decline to Answer
Using condoms breaks up the rhythm of sex. (Choose one)
Yes
No
Decline to Answer
Using condoms would help build trust between my partner and me. (Choose one)
Yes
No
Decline to Answer
Self-Efficacy about Negotiation and Condom Use
The next questions ask about which kinds of situations are more difficult for you to use condoms when you have sex with your partner. Even if the situation has not happened to you, try to imagine how you would handle it if it ever happened.
Can you discuss condom use with your partner? (Choose one)
Yes
Maybe
No
Decline to answer
Can you insist on condom use if your partner does not want to use one? (Choose one)
Yes
Maybe
No
Decline to answer
Can you stop and look for condoms when you are sexually aroused? (Choose one)
Yes
Maybe
No
Decline to answer
Can you insist on condom use every time you have sex even when you are under the influence of drugs or alcohol? (Choose one)
Yes
Maybe
No
Decline to answer
Can you insist on condom use every time you have sex even when your partner is under the influence of drugs? (Choose one)
Yes
Maybe
No
Decline to answer
Can you insist on condom use every time you have sex even if you or your partner uses another method to prevent pregnancy? (Choose one)
Yes
Maybe
No
Decline to answer
Can you put a condom on your partner without spoiling the mood? (Choose one)
Yes
Maybe
No
Decline to answer
Self-Efficacy about Using Condoms
The next questions are about your confidence in using condoms. Even if you’ve never used condoms before, think about how confident you would be if you were to use them in the future.
HOW CONFIDENT (SURE) ARE YOU THAT YOU COULD…
Put a condom on a hard penis. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer
Unroll a condom down correctly on the first try. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer
Start over with a new condom if you placed it on the wrong way. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer
Unroll a condom fully to the base of the penis. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer
Squeeze air from the tip of a condom. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer
Take a male condom off without spilling the semen or cum. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer
Take a male condom off before partner loses their hard on. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer
Dispose of a used condom properly. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer
Use lubricant with a condom. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer
Knowledge about HIV
The next questions are about your knowledge of HIV. Select “True” or “False.”
You have to take a test to know if you have HIV. (Choose one)
True
False
Decline to answer
A positive HIV test means that you have AIDS. (Choose one)
True
False
Decline to answer
Condoms can help protect you from transmitting or becoming infected with HIV. (Choose one)
True
False
Decline to answer
Having sex with someone who has HIV is the only way to get HIV. (Choose one)
True
False
Decline to answer
It is important to use a condom if both you and your partner have HIV. (Choose one)
True
False
Decline to answer
There are different types of HIV infections. (Choose one)
True
False
Decline to answer
Female condoms can stop you from getting HIV. (Choose one)
True
False
Decline to answer
Having anal sex without a condom makes it easier to get HIV. (Choose one)
True
False
Decline to answer
Having a STD can make it easier to get HIV. (Choose one)
True
False
Decline to answer
Having a STD can make it harder to manage your HIV. (Choose one)
True
False
Decline to answer
Coping Style
There are a lot of things people can do when they have problems. These questions are about ways you’ve dealt with your problems recently. Tell me how often you have done each of the below in the last three months.
IN THE LAST 3 MONTHS, HAVE YOU…
Tried to keep your feelings to yourself? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
Tried to keep your feelings from interfering with other things too much? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
Tried to keep others from knowing how bad things are? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
Wished the situation would go away? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
Hoped a miracle would happen? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
Drank alcohol to deal with your problems? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
Had sex to deal with your problems? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
Used drugs (other than alcohol) to deal with your problems? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
Thought your problems were no big deal? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
Tried to forget about the whole thing? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
Gone on as if nothing had happened? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
Knew what had to be done, so you doubled your efforts to make things work? (Choose one.)
Never
A few times
Lots of times
All of the time
Decline to answer
Made a plan of action and followed it? (Choose one.)
Never
A few times
Lots of times
All of the time
Decline to answer
Just concentrated on what you had to do next? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
Talked to someone to find out more about the situation? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
Talked to someone about your feelings? (Choose one.)
Never
A few times
Lots of times
All of the time
Decline to answer
Talked to someone who could help do something about the problem? (Choose one.)
Never
A few times
Lots of times
All of the time
Decline to answer
Rediscovered what is important in life? (Choose one.)
Never
A few times
Lots of times
All of the time
Decline to answer
Saw the situation as an opportunity to change or grow in a good way? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
Social Support Network
The next questions are about the people in your social network. Social network refers to the people that you are connected to through different types of relationships, including your friends and family members.
How many friends and/or family members loan you money, take care of you, or help you in an emergency?
_________ (Enter total # of people, or 0 if none) [QDS Skip: If 0, skip to Q144]
Decline to answer
How often do you talk to these people who loan you money, take care of you, or help you in an emergency either on the phone or in-person? (Choose one)
About everyday
Twice a week
Once a week
Twice a month
Once a month or less
Decline to answer
How many friends and/or family members can you really talk to, rely on, and can understand you?
_________ (Enter total # of people, or 0 if none) [QDS Skip: If 0, skip to Q146]
Decline to answer
How often do you talk to these people whom you can really talk to, rely on, and who can understand you either on the phone or in-person? (Choose one)
About everyday
Twice a week
Once a week
Twice a month
Once a month or less
Decline to answer
How many friends and/or or family members provide you with information or advice?
_________ (Enter total # of people, or 0 if none) [QDS Skip: If 0, skip to Q148]
Decline to answer
How often do you talk to these people who provide you with information or advice either on the phone or in-person (Choose one)
About everyday
Twice a week
Once a week
Twice a month
Once a month or less
Decline to answer
How many friends and/or family members can you talk to about what it is like to have HIV?
_________ (Enter total # of people, or 0 if none) [QDS Skip: if 0, skip to Q150]
Decline to answer
How often do you talk to these people either on the phone or in-person? (Choose one)
About everyday
Twice a week
Once a week
Twice a month
Once a month or less
Decline to answer
How many of the people in your life are domineering, try to tell you how to run your life, or give unwanted advice?
_________ (Enter total # of people, or 0 if none) [QDS Skip: If 0, skip to Q152]
Decline to answer
How often do you talk to these people who are domineering, try to tell you how to run your life, or give unwanted advice either on the phone or in-person? (Choose one)
About everyday
Twice a week
Once a week
Twice a month
Once a month or less
Decline to answer
How many friends and/or family members tell you that you should use a condom when you have sex?
_________ (Enter total # of people, or 0 if none) [QDS Skip: If 0, skip to Q154]
Decline to answer
How often do you talk on the phone or in-person to these people who tell you that should use a condom when you have sex?
About everyday
Twice a week
Once a week
Twice a month
Once a month or less
Decline to answer
How many of your friends and/or family members tell you that you don’t need to wear a condom during
sex?
_________ (Enter total # of people)
Decline to answer [QDS Skip: If 0, skip to end of interview]
How often do you talk to these people either on the phone or in-person who tell you that you don’t need to wear a condom during sex? (Choose one)
About everyday
Twice a week
Once a week
Twice a month
Once a month or less
Decline to answer
| File Type | application/msword |
| File Title | Social Networks Demonstration Project |
| Author | DHAP USER |
| Last Modified By | CDC User |
| File Modified | 2014-05-14 |
| File Created | 2014-05-14 |