Form 1 HIV Risk Factor Questionnaire English

HIV Study in Blood Donors from Five Chinese Regions (NHLBI)

Attachment_1.1_HIV_Risk_Factor_Q_English_11_2014_V_8.0

HIV Risk Factor Questionnaire Blood donors Control Peripheral Sites

OMB: 0925-0596

Document [docx]
Download: docx | pdf

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0925-0596. The time required to complete this information collection is estimated to average 18 minutes per response, including the time to review instructions, search existing data sources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0596). Do not return the completed form to this address.

OMB Number: 0925-0596

OMB Expiration Date: XX/XX/XXX





HIV risk factorquestionnaire (English Translation)



RECIPIENT EPIDEMIOLOGY AND DONOR EVALUATION STUDY-III (REDS-III)

HIV RISK FACTOR QUESTIONNAIRE







Date: __ __/__ __/__ __ __ __ (D D/ M M / Y Y Y Y)



Study identification number: __ - __ __ __ __ __ __ __ - __

RETROVIRUS EPIDEMIOLOGY DONOR STUDY-III (REDS-III)

HIV RISK FACTOR QUESTIONNAIRE

Date: __ __/__ __/__ __ __ __ (D D/ M M / Y Y Y Y)

Study identification number: __ - __ __ __ __ __ __ __ - __

Instructions: Please answer each of the following questions about your health, lifestyle, and blood donation history. For each question, provide a response unless directed to skip to another question further down in the questionnaire. It will take approximately 20 minutes to complete these questions.

  1. Your Background

  1. When were you born?


__ __ __ __ (year)


  1. What is your gender?


Female

Male


  1. What is your place of birth?


Province:____________________________

City:________________________________


County:______________________________

  1. What is your ethnicity?


Han

Hui

Uygur

Man

Dai

Zhuang

Other, specify ______________


  1. What is your current occupation?












5a. Have you ever provided special services at entertainment business (including night clubs, private clubs, night bar, Karaoke clubs)?


Worker

Farmer who works at hometown

Farmer or worker working out of town

Service or business

Education/research/government

Military/Police

Medicine/Health care

Student

Company employee

Self-employed

Other, specify _____________


Yes (please describe)__________________________

No

Unknown




  1. What is the highest level of education you have received?

Primary school or less

Junior high school

High School or vocational school

Associate degree

Bachelor’s degree

Graduate level degree

Other, specify _____________

  1. What is your marital status?


Never married

Married or co-habiting

Divorced

Separated

Widowed

Other, specify _____________




  1. History of Blood Donation & Infection Risks


  1. How many times have you donated blood?

__ __ time (s)ANSWER QUESTION 8a-8c


Please list the most recent three blood donations indicating the year and type of blood donation for each.(If you have donated blood more than 3 times, please list the most recent three):


Donation

Year

Type of Donation

8a. Most recent donation

__ __ __ __

Whole blood donation

Apheresis donation

8b. Next most recent donation

__ __ __ __

Whole blood donation

Apheresis donation

8c. Next most recent donation

__ __ __ __

Whole blood donation

Apheresis donation


  1. How much do you agree or disagree with each of the statements (9a-9c) below:

Statement

Do not

agree

at all

Disagree

a little

Agree a

little

Agree

very

much

9a. It’s important that I received blood test results from blood donation.

9b. I think blood donation is a good, fast, anonymous way to get my blood test result.

9c. One of my reasons for donating blood is to find out if I have HIV and/or hepatitis infection.




  1. Have you ever been told that you are at risk for spreading diseases through your blood?



10a. What kind of diseases? (Mark all that apply)








10b. When was the last time you were told so?


YesANSWER QUESTION 10a

No Skip to Q11

UnknownSkip to Q11


Hepatitis A

Hepatitis B

Hepatitis C

Syphilis/Gonorrhea

HIV/AIDS

Other, specify __________

Unknown



Within 3 days up to 1 month

Within 1-3 months

Within 3-6 months

From 6 months to less than 1 year

1 year ago

Unknown

  1. Did you ever receive notification from blood center about your infection status?



11a. Before your most recent donation, had you ever received notification from blood center about your infection status (excluding any such notification after your most recent blood donation)?


11b. Had you sought further testing or health care according to the instruction of the notification (excluding any such notification after your most recent blood donation)?



11c. Are you planning to seek further testing or health care according to the instruction of the notification?

YesANSWER QUESTION 11a-11c

No Skip to Q12

UnknownSkip to Q12



Yes

No

Unknown




Yes

No

Unknown



Yes

No

Unknown

  1. Before your most recent donation, had you ever been permanently deferred as a blood donor?



12a. For what reason were you permanently deferred?(Mark all that apply)

YesANSWER QUESTION 12a

NoSKIP TO 13

UnknownSKIP TO 13



Hepatitis B

Hepatitis C

Syphilis

HIV

Didn’t pass Physical Exam, specify ________

Didn’t pass blood Test, specify __________

Other, specify ______________________


  1. Before your most recent donation, had you ever been temporarily deferred as a blood donor?



13a. For what ineligibility were you temporarily deferred?(Mark all that apply)


YesANSWER QUESTION 13a

NoSKIP to Q 14

UnknownSKIP to Q14


HBV rapid test

ALT

Hemoglobin (Hb) level

Blood pressure

Heart rate

Body Weight

Fasting

Other, specify ______________________




  1. Health Condition History


  1. Have you ever received acupuncture treatment?




14a. In the past6 months, did you have acupuncture?


Yes ANSWER QUESTION 14a

NoSKIP TO 15

UnknownSKIP TO 15



Yes

No

Unknown

  1. In the past 6 months, did you have any injection (including intravenous [IV] and intramuscular [IM] injections)?



15a. How many times did you have injection(s)?


Yes ANSWER QUESTION 15a

NoSKIP TO 16

UnknownSKIP TO 16



__ __ times


  1. Have you had any finger sticks (excluding the one prior to making a donation)?



16a. In the past 6 months, did you have finger sticks (other than the one prior to making a donation)?

YesANSWER QUESTION 16a

NoSKIP TO 17

UnknownSKIP TO 17


Yes

No

Unknown




  1. When you had acupuncture, finger sticks, or injections, were needles and syringes used disposable?


Were needles and syringes used disposable?

Seldom

Sometimes

Often

Always

Unknown

a. Acupuncture

b. Finger sticks

c. Injections



  1. In the past 6 months, have you ever visited the following medical facilities?(Mark all that apply)








18a. What kind of treatment did you receive from the above medical facilities?(Mark all that apply)





Yes, county hospitalANSWER QUESTION 18a

Yes, town hospitalANSWER QUESTION 18a

Yes, community hospitalANSWER QUESTION 18a

Yes, village clinicANSWER QUESTION 18a

Yes, private outpatient clinicANSWER QUESTION 18a

Yes, other, please specifyANSWER QUESTION 18a

No SKIP TO 19

UnknownSKIP TO 19



Intravenous (IV) or intramuscular (IM)injection

Therapeutic transfusion

Outpatient surgeries (including anesthesia, removal of sebaceous cyst, wound suture etc.)

Dental care

Pediatrician visit or accompany for someone else

Other, please specify__________


  1. Have you ever had in-patient medical surgery?




19a. In the past 6 months, did you have in-patient medical surgery?

YesANSWER QUESTION 19a

NoSKIP TO 20

UnknownSKIP TO 20



Yes

No

Unknown


  1. Have you ever had out-patient medical surgery?




20a. In the past 6 months, did you have out-patient medical surgery?


Yes ANSWER QUESTION 20a

NoSKIP TO 21

UnknownSKIP TO 21



Yes

No

Unknown


  1. Have you ever had cosmetic surgery (e.g. laser, eye/lip surgery, collagen injection, dermal abrasion)?



21a. In the past 6 months, did you have cosmetic surgery?


Yes ANSWER QUESTION 21a

NoSKIP TO 22

UnknownSKIP TO 22



Yes

No

Unknown


  1. Have you ever received a blood transfusion?



22a. How many times did you have blood transfusions?



22b. Year of your first time of blood transfusion?



22c. Year of your last time of blood transfusion?

YesANSWER22a-22c

NoSKIP TO 23

UnknownSKIP TO 23

__ __ times




__ __ __ __ (year)



__ __ __ __ (year)



  1. Have you ever had any dental cleaning?




23a. In the past 6 months, did you have dental cleaning?

YesANSWER QUESTION 23a

NoSKIP TO 24

UnknownSKIP TO 24



Yes

No

Unknown

  1. Have you ever had any dental surgery, such as root canal treatment or tooth extraction?



24a. In the past 6 months, did you have dental surgeries?

YesANSWER QUESTION 24a

NoSKIP TO 25

UnknownSKIP TO 25


Yes

No

Unknown


  1. Have you ever had any endoscopy (such as gastroscopy and colonoscopy)?




25a. In the past 6 months, did you have endoscopies?


YesANSWER QUESTION 25a

NoSKIP TO 26

UnknownSKIP TO 26



Yes

No

Unknown


  1. Have you ever been previously diagnosed with hepatitis?



26a. What type(s) of hepatitis did you have (please choose all that apply)?

YesANSWER QUESTION 26a

NoSKIP TO 27

UnknownSKIP TO 27


Hepatitis A

Hepatitis B

Hepatitis C

Other, specify _____________

Unknown


  1. Have you ever been previously diagnosed with syphilis, gonorrhea, or any other sexually transmitted disease?


Yes

No

Unknown


  1. Have any of your family members had hepatitis?


Yes

No

Unknown?


  1. Have any of your family members had HIV/AIDS?



Yes

No

Unknown

  1. Have you ever had household contact with someone with HIV/AIDS?




30a. In the past 6 months, did you have household contact with someone with HIV/AIDS?

YesANSWER QUESTION 30a

NoSKIP TO 31

UnknownSKIP TO 31



Yes

No

Unknown





  1. Drug Use History

  1. Have you ever used needles to shoot (or take) street drugs?



31a. How long have you shot (or taken) street drugs?

31b. How many times per month did you shoot (or take) street drugs?



31c. Have you ever shared needles or syringes with others to inject street drugs?





31d. In the past 6 months, did you ever use needles to shoot (or take) street drugs?

YesANSWER QUESTIONS 31a-31d

NoSKIP TO 32

UnknownSKIP TO 32


__ __ years




__ __ times/month





Yes

No

Unknown




Yes

No

Unknown


  1. Have you ever used illegal oral or intranasal drugs without doctor’s prescription?



32a. In the past 6 months, did you use illegal oral or intranasal drugs without doctor’s prescription

YesANSWER QUESTION 32a

NoSKIP TO 33

UnknownSKIP TO 33


Yes

No

Unknown



  1. Have you ever lived with a person who was an intravenous drug user?




3a. In the past 6 months, did you live with a person who was an intravenous drug user?

YesANSWER QUESTION 33a

NoSKIP TO 34

UnknownSKIP TO 34



Yes

No

Unknown

  1. Are any of your close friends or family member’s intravenous drug users?

Yes

No

Unknown



  1. Sexual History



The next section of questions will ask you about your sexual experiences. In these questions, include only those people you have had oral, vaginal, or anal sex with. Do not include people that you have just kissed. Please note that for the next few questions the term "sex" refers to any of the following activities, whether or not a condom or other protection was used: Vaginal sex (contact between penis and vagina), Oral sex (mouth or tongue on someone’s vagina, penis, or anus), Anal sex (contact between penis and anus).

  1. Have you had more than 2 concurrent sexual partners of the opposite sex?




35a1. In your lifetime, how many heterosexual partners did you have?






35a2. In the past 6 months, how many heterosexual partners did you have?





35b1. How often do you or your sex partner use a condom when you have sex with your heterosexual partner?





35b2. In the past 6 months, how often do you or your sex partner use a condom when you have sex with your heterosexual partner?


YesANSWER QUESTIONS35a1-35b2

NoSKIP TO 36

UnknownSKIP TO 36



1-2

3-4

5-7

8-10

>10



1-2

3-4

5-7

8-10

>10


Never

Sometimes

Half of time

Most of time

Always



Never

Sometimes

Half of time

Most of time

Always



  1. (FOR MALE RESPONDENTS ONLY) In your lifetime, have you ever had sex with another male?




36a1. In your lifetime, how many times did you have sex with males?





36a2. In your lifetime, how many male partners have you had sex with?




36a3. In your lifetime, how often do you or your sex partner use a condom when you have sex with male partner?






36b1. In the past 6 months, how many times did you have sex with males?





36b2. In the past 6 months, how many male partners have you had sex with?





36b3. In the past 6 months, how often do you or your sex partner use a condom when you have sex with male partner?


YesANSWERQUESTIONS 36a1-36b3

NoSKIP TO 37

UnknownSKIP TO 37



1-2

3-5

6-10

>10



1-2

3-5

6-10

>10




Never

Sometimes

Half of time

Most of time

Always



1-2

3-5

6-10

>10




1-2

3-5

6-10

>10


Never

Sometimes

Half of time

Most of time

Always


  1. Have you ever paid or received money or other forms of remuneration for having sex?




37a. In the past 6 months, have you paid or received money or other forms of remuneration for having sex?

YesANSWER QUESTIONS37a

NoSKIP TO 38

UnknownSKIP TO 38



Yes

No

Unknown

  1. Have you ever had a sex partner who was an intravenous drug user?




38a. In the past 6 months, did you have a sex partner who was an intravenous drug user?



YesANSWER QUESTION 38a

NoSKIP TO 39

UnknownSKIP TO 39



Yes

No

Unknown


  1. In your lifetime, have you ever had a sex partner who had a positive test for syphilis, gonorrhea, or any other sexually transmitted disease?



39a. In the past 6 months, did you have a sex partner who had a positive test for syphilis, gonorrhea, or any other sexually transmitted disease?


YesANSWER QUESTION 39a

NoSKIP TO 40

UnknownSKIP TO 40



Yes

No

Unknown


  1. In your lifetime, have you ever had a sex partner who had been diagnosed with HIV/AIDS?



40a. In the past 6 months, did you have a sex partner who had been diagnosed with HIV/AIDS?


YesANSWER QUESTION 40a

NoSKIP TO 41

UnknownSKIP TO 41



Yes

No

Unknown


  1. In your lifetime, have you had sexual contact with anyone who received blood transfusion?



41a. In the past 6 months, did you have sexual contact with anyone who received blood transfusion?


YesANSWER QUESTION 41a

NoSKIP TO 42

UnknownSKIP TO 42



Yes

No

Unknown







  1. Other Risk Factors

  1. Have you ever had contact with human blood and other human body fluids in your workplace?



42a. In the past 6 months did you ever have contact with human blood and other human body fluids in your workplace?


YesANSWER QUESTION 42a

NoSKIP TO 43

UnknownSKIP TO 43


Yes

No

Unknown


  1. Have you ever had a tattoo?




43a. In the past 6 months, did you have a tattoo?


YesANSWER QUESTION 43a

NoSKIP TO 44

UnknownSKIP TO 44


Yes

No

Unknown



  1. Have you ever had your ears or other body parts pierced?




44a. In the past 6 months, did you have your ears or other body parts pierced?


YesANSWER QUESTION 44a

NoEND

UnknownEND



Yes

No

Unknown






Thank you very much for your participation!

Thank you for your contribution to our blood safety research!



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
Authorlshi
File Modified0000-00-00
File Created2021-01-26

© 2024 OMB.report | Privacy Policy