CSAP Adult CSAP Adult

ATTACHMENT 5

OMB No. 0930-XXXX

Expiration Date XX/XX/XXXX

Questions for Prevention Programs

Adult Version- Participants Age 18 and Older

(Revised 09/17/2014)

Public reporting burden for this collection of information is estimated to average 27 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, if all items are asked of a participant; to the extent that providers already obtain much of this information as part of their ongoing participant intake or follow up, less time will be required. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 2-1057, 1 Choke Cherry Road, Rockville, MD 20857. 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. The control number for this project is 0930-xxxx.

SECTION A

RECORD MANAGEMENT

THIS SECTION TO BE COMPLETED BY STAFF ONLY

Participant ID |____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|

Grant ID |____|____|____|____|____|____|____|____|____|____|

1. Data Collection Type [SELECT ONLY ONE TYPE]

� Baseline

� Exit

� First follow-up after exit

� Second follow-up after exit

2a. Was the data collected?

� Yes

� No

2b. When did the data collection take place?

Date |____|____| / |____|____| / |____|____|____|____|

Month Day Year

END SECTION A

RECORD MANAGEMENT

SECTION B

FACTS ABOUT YOU

First, we’d like to ask some basic questions about you. Your answers will not be used to identify you in any way. Instead, your answers will help us understand how different groups (like men or women, or people of similar ages) feel about substance abuse and HIV prevention.

3. What is your date of birth? (MONTH AND YEAR MUST BE ENTERED. DAY IS OPTIONAL AND WILL NOT BE SAVED IN THE CDP SYSTEM)

|____|____| / |____|____| / |____|____|____|____|

Month Day Year

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

 

4.   What is your gender?

 

         Male

         Female

         Different identity (SPECIFY): __________________________________

         DECLINED

         DON’T KNOW/INFORMATION NOT AVAILABLE

 

5.   Which one of the following do you consider yourself to be?

 

         Straight

         Lesbian (if female) or Gay (if male)

         Bisexual

         DECLINED

         DON’T KNOW/INFORMATION NOT AVAILABLE

6. People are different in their sexual attraction to other people. Which statement best describes your feelings?

[IF MALE]	[IF FEMALE]
� I am only attracted to females	� I am only attracted to males
� I am mostly attracted to females	� I am mostly attracted to males
� I am equally attracted to females and males	� I am equally attracted to males and females
� I am mostly attracted to males	� I am mostly attracted to females
� I am only attracted to males	� I am only attracted to females
� DECLINED	� DECLINED
� DON’T KNOW/INFORMATION NOT AVAILABLE	� DON’T KNOW/INFORMATION NOT AVAILABLE

SECTION B

FACTS ABOUT YOU (CONTINUED)

7. In the past 12 months who have you had sex with?

� Men only

� Women only

� Both men and women

� I have not had sex in the past 12 months

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

8. Are you Hispanic, Latino/a, or Spanish origin? (One or more categories may be selected)

� Yes, Central American

� Yes, Cuban

� Yes, Dominican

� Yes, Mexican, Mexican American, Chicano/a

� Yes, Puerto Rican

� Yes, South American

� Yes, another Hispanic, Latino, or Spanish origin

� No, not of Hispanic, Latino/a, or Spanish origin

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

9. What is your race? (One or more categories may be selected)

� White

� Black or African American

� American Indian

� Alaska Native

� Asian Indian

� Chinese

� Filipino

� Japanese

� Korean

� Vietnamese

� Other Asian

� Native Hawaiian

� Guamanian or Chamorro

� Samoan

� Other Pacific Islander

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

10. How well do you speak English?

� Very well

� Well

� Not well

� Not at all

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

SECTION B

FACTS ABOUT YOU (CONTINUED)

11. Do you speak a language other than English at home?

� Yes

� No [SKIP TO QUESTION 13]

� DECLINED [SKIP TO QUESTION 13]

� DON’T KNOW/INFORMATION NOT AVAILABLE [SKIP TO QUESTION 13]

12. If you speak a language other than English at home, what language do you speak?

� Spanish

� Other language Identify other language: ___________________

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

13. Are you deaf or do you have serious difficulty hearing?

� Yes

� No

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

14. Are you blind or have serious difficulty seeing, even when wearing glasses?

� Yes

� No

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

15. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering or making decisions?

� Yes

� No

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

16. Do you have serious difficulty walking or climbing stairs?

� Yes

� No

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

SECTION B

FACTS ABOUT YOU (CONTINUED)

17. Do you have difficulty dressing or bathing?

� Yes

� No

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

18. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?

� Yes

� No

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

19. What is the highest level of education you have finished, whether or not you received a degree?

 Preschool

 Kindergarten

 1st Grade

 2nd Grade

 3rd Grade

 4th Grade

 5th Grade

 6th Grade

 7th Grade

 8th Grade

 9th Grade

 10th Grade

 11th Grade

 12th Grade/High School Diploma Equivalent

 Some College or University

 Bachelor’s Degree (BA, BS) or Higher

 Vocational/Tech Diploma After High School

 I never attended school or a job training program

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

SECTION B

FACTS ABOUT YOU (CONTINUED)

20. Are you currently employed?

[CLARIFY BY FOCUSING ON STATUS DURING MOST OF THE PREVIOUS WEEK, DETERMINING WHETHER PARTICIPANT WORKED AT ALL OR HAD A REGULAR JOB BUT WAS OFF WORK.]

 Employed full time (35+ hours per week, or would have been)

 Employed part time

 Unemployed, looking for work [SKIP TO QUESTION 22]

 Unemployed, disabled [SKIP TO QUESTION 22]

 Unemployed, volunteer work [SKIP TO QUESTION 22]

 Unemployed, retired [SKIP TO QUESTION 22]

 Unemployed, not looking for work [SKIP TO QUESTION 22]

 Other (Specify) ___________________

� DECLINED [SKIP TO QUESTION 22]

� DON’T KNOW/INFORMATION NOT AVAILABLE [SKIP TO QUESTION 22]

21a. If employed, are you paid at or above the minimum wage?

 Yes

 No

 DECLINED

 DON’T KNOW/INFORMATION NOT AVAILABLE

21b. If employed, are your wages paid directly to you by your employer?

 Yes

 No

 DECLINED

 DON’T KNOW/INFORMATION NOT AVAILABLE

21c. If employed, could anyone have applied for this job?

 Yes

 No

 DECLINED

 DON’T KNOW/INFORMATION NOT AVAILABLE

22. In the past 30 days, how many nights have you spent in jail/prison?

|____|____| nights  

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

SECTION B

FACTS ABOUT YOU (CONTINUED)

23. Describe your current relationship status.

Single (never married)

Informally married or living with a permanent partner

Legally married

Separated

Divorced or broken up from an informal marriage

Widowed

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

24. Think about the household members that live with you right now. About how much income have you and/or your family members made in the last year before taxes? (Include child support and/or cash payments from the government, for example, welfare [TANF], SSI, or unemployment compensation)

$0 - $10,000

$10,001 - $20,000

$20,001 - $30,000

$30,001 - $40,000

$40,001 - $50,000

$50,001 - $60,000

More than $60,000

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

25. Have you ever served on active, reserve, or National Guard duty?

   Yes

         No (SKIP TO QUESTION 27)

        DECLINED (SKIP TO QUESTION 27)

         DON’T KNOW/INFORMATION NOT AVAIABLE (SKIP TO QUESTION 27)

26a. If you ever served on active, reserve, or National Guard duty, in what branch of the military/uniformed services did you serve?

         Army

         Marine Corps

         Navy

         Air Force

         Coast Guard

         PHS

         NOAA

         DECLINED

         DON’T KNOW/INFORMATION NOT AVAILABLE

26b. If you ever served on active, reserve, or National Guard duty, in which component did you serve?

   Active

         Reserve

         National Guard

         DECLINED

         DON’T KNOW/INFORMATION NOT AVAILABLE

26c. If you ever served on active, reserve, or National Guard duty, are you currently on active duty or are you separated or retired?

         On active duty

         Separated

         Retired

         DECLINED

         DON’T KNOW / INFORMATION NOT AVAILABLE

26d. If you ever served on active, reserve, or National Guard duty, have you ever been deployed to a     combat zone? (SELECT ALL THAT APPLY)

         No, never deployed to a combat zone

         Yes, Iraq or Afghanistan (e.g., OEF/OIF/OND)

         Yes, Persian Gulf (Operation Desert Shield/Desert Storm)

         Yes, Vietnam/Southeast Asia

         Yes, Korea

         Yes, Persian Gulf (Operation Desert Shield/Desert Storm)

         Yes, World War II

         Yes, other (SPECIFY COMBAT ZONE): __________________________________

         DECLINED

         DON’T KNOW / INFORMATION NOT AVAILABLE

For the following questions, immediate family includes your spouse or partner, and your parents, children, brothers and sisters, whether they are biological, step, or adoptive.  Please include these family members whether or not they live with you.

27. Is anyone in your immediate family currently serving as a member of one the branches of the

      United States uniformed services on active duty, reserve components or National Guard?

         Yes

         No (SKIP TO SECTION C)

         DECLINED (SKIP TO SECTION C)

         DON’T KNOW / INFORMATION NOT AVAILABLE (SKIP TO SECTION C)

28a. If anyone in your immediate family is currently serving in the uniformed services, which member(s) are currently serving? (SELECT ALL THAT APPLY)

         My spouse

         Unmarried partner

         My mother

         My father

         My son or sons

         My daughter or daughters

         My brother or brothers

         My sister or sisters

         Another member of my immediate family (SPECIFY RELATIONSHIP): ________________

         DECLINED

         DON’T KNOW/INFORMATION NOT AVAILABLE

END SECTION B

FACTS ABOUT YOU

SECTION C

ATTITUDES & KNOWLEDGE

Next, we’d like to ask you how you feel about substance use and health care services. Again, your answers are private and will not be used to identify you.

The next few questions ask about HOW MUCH you think people RISK HARMING themselves physically or in other ways by using alcohol, tobacco, and drugs.

29. How much do people risk harming themselves physically or in other ways when they smoke one or more packs of cigarettes per day?

No risk

Slight risk

Moderate risk

Great risk

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

30. How much do people risk harming themselves physically or in other ways when they smoke marijuana once or twice a week?

No risk

Slight risk

Moderate risk

Great risk

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

31. How much do people risk harming themselves physically or in other ways when they have five or more drinks of an alcoholic beverage once or twice a week?

No risk

Slight risk

Moderate risk

Great risk

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

32. If you have children, during the past 12 months, how many times have you talked with your children about the dangers or problems associated with the use of tobacco, alcohol, or drugs?

� I don’t have any children

� 0 times

� 1 or 2 times

A few times

Many times

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

END SECTION C

ATTITUDES & KNOWLEDGE

SECTION D

BEHAVIOR & RELATIONSHIPS

SECTION D1

CIGARETTES, ALCOHOL, DRUGS

The next question is about CIGARETTES.

Think back over the past 30 days and record on how many days, if any, you used cigarettes.

33. During the past 30 days, on how many days did you smoke part or all of a cigarette? (Includes menthol and regular cigarettes and loose tobacco rolled into cigarettes)

|___| ___| Number of days in past 30 days

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

The next question asks about other tobacco products. Please include any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe

34. During the past 30 days, on how many days did you use OTHER tobacco products?

|___| ___| Number of days in past 30 days

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

The next question is about ALCOHOL. By alcohol, we mean BEER, WINE, WINE COOLERS, MALT BEVERAGES or HARD LIQUOR.

Different groups of people in the United States may use alcohol for religious reasons. For example, some churches serve wine during a church service. If you drink wine at church or for some other religious reason, do not count these times in your answers to the questions below.

Think back over the past 30 days and record on how many days, if any, you consumed alcohol in the amount described below.

35. [ASK ONLY TO WOMEN 21 YEARS OLD OR OLDER ONLY; OTHERWISE SELECT NOT APPLICABLE]

During the past 30 days, on how many days did you have 3 more drinks on the same occasion? [By 'occasion,' we mean at the same time or within a couple of hours of each other].

|___| ___| Number of days in past 30 days

� NOT APPLICABLE – PARTICIPANT IS MALE OR UNDER THE AGE OF 21

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

SECTION D1

CIGARETTES, ALCOHOL, DRUGS AND RECOVERY (CONTINUED)

36. [ASK ONLY TO MEN 21 YEARS OLD OR OLDER ONLY; OTHERWISE SELECT NOT APPLICABLE]

During the past 30 days, on how many days did you have 4 or more drinks on the same occasion? [By 'occasion,' we mean at the same time or within a couple of hours of each other].

|___| ___| Number of days in past 30 days

� NOT APPLICABLE – PARTICIPANT IS FEMALE OR UNDER THE AGE OF 21

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

The next question is about MARIJUANA or HASHISH. Marijuana is sometimes called weed, blunt, hydro, grass, or pot. Hashish is sometimes called hash or hash oil.

Think back over the past 30 days and record on how many days, if any, you used marijuana or hashish.

37. During the past 30 days, on how many days did you use marijuana or hashish?

|___| ___| Number of days in past 30 days

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

The next question is about OTHER ILLEGAL DRUGS, excluding marijuana or hashish.

These include substances like inhalants or sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, or shoe polish (used to feel good or get high), heroin, crack, or cocaine, methamphetamine, hallucinogens (drugs that cause people to see or experience things that are not real) such as LSD (sometimes called acid), Ecstasy (MDMA), PCP, peyote (sometimes called angel dust), and prescription drugs used without a doctor’s orders.

Think back over the past 30 days and record on how many days, if any, you used illegal drugs OTHER THAN MARIJANNA AND HASSISH.

38. During the past 30 days, on how many days did you use any illegal drug OTHER THAN MARIJUANNA AND HASSISH?

|___| ___| Number of days in past 30 days

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

SECTION D1

CIGARETTES, ALCOHOL, DRUGS AND RECOVERY (CONTINUED)

Now we would like to ask about your use of prescription drugs without a doctor’s orders during the past 30 days.

39. During the past 30 days, on how many days have you used prescription drugs without a doctor’s orders?

|___| ___| Number of days in past 30 days

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

The next few questions ask about programs or classes you may have attended recently.

40. In the past 30 days, did you attend any voluntary self-help groups for recovery that were not affiliated with a religious or faith-based organization?

In other words, did you participate in a non-professional, peer-operated organization that is devoted to helping individuals who have addiction related problems such as: Alcoholics Anonymous, Narcotics Anonymous, Oxford House, Secular Organization for Sobriety, or Women for Sobriety, etc.

� Yes If yes, |___| ___| Number of times in past 30 days

� No

� DECLINED

� DON’T KNOW/INFORMATION OT AVAILABLE

41. In the past 30 days did you attend any religious/faith affiliated recovery self-help groups?

� Yes If yes, |___| ___| Number of times in past 30 days

� No

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

42. In the past 30 days, did you attend meetings of organizations that support recovery other than the organizations described above?

� Yes If yes, |___| ___| Number of times in past 30 days

� No

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

END SECTION D1

CIGARETTES, ALCOHOL, DRUGS AND RECOVERY

SECTION D2

VIOLENCE AND TRAUMA

The next few questions ask about abuse you might have experienced.

43. In your life have you ever experienced an event, series of events, or set of circumstances that resulted in you feeling physically or emotionally harmed or threatened?

� Yes

� No [SKIP TO QUESTION 45]

� DECLINED [SKIP TO QUESTION 45]

� DON’T KNOW/INFORMATION NOT AVAILABLE [SKIP TO QUESTION 45]

44. What kind of event was this? (Please select all that apply):

� Natural or man-made disaster

� Community or school violence

� Interpersonal violence (including physical, sexual or psychological)

� Military trauma

• Other (SPECIFY): __________________________________

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

45. In the past 30 days, how often have you been hit, kicked, slapped, or otherwise physically hurt?

Never

A few times

More than a few times

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

END SECTION D2

VIOLENCE AND TRAUMA

END SECTION D

SECTION E

HEALTH AND HEALTH CARE SERVICES

46. Would you know where to go in your neighborhood to see a health care professional regarding HIV/AIDS or other sexually transmitted health issues?

Yes

No

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

47. Would you know where to go in your neighborhood to see a health care professional regarding a drug or alcohol problem?

� Yes

� No

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

48. Do you currently have health care or medical insurance? (Select all that apply)

Yes, private insurance

Yes, Medicare

Yes, Medicaid

Yes, public assistance other than Medicare or Medicaid (e.g. TRICARE)

No

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

49. Have you seen a doctor, nurse, or other health care provider in the past 12 months?

Yes

No

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

50. During the past 30 days, did you engage in any sexual activity?

� Yes

� No [SKIP TO SECTION F IF APPLICABLE TO YOUR PROGRAM]

� DECLINED [SKIP TO SECTION F IF APPLICABLE TO YOUR PROGRAM]

� DON’T KNOW [SKIP TO SECTION F IF APPLICABLE TO YOUR PROGRAM]

� NOT PERMITTED TO ASK [SKIP TO SECTION F IF APPLICABLE TO YOUR PROGRAM]

SECTION E

HEALTH AND HEALTH CARE SERVICES (CONTINUED)

51a. In the past 30 days, did you engage in protected or unprotected—

	Yes, Protected	Yes, Unprotected	No	DECLINED	DON’T KNOW
(1) Vaginal sexual Contacts	�	�	�	�	�
(2) Oral sexual contacts	�	�	�	�	�
(3) Anal sexual contacts	�	�	�	�	�

51b. In the past 30 days did you engage in unprotected sexual contact with an individual who is or was:

	Yes	No	DECLINED	DON’T KNOW
(1) HIV positive or has AIDS	�	�	�	�
(2) An injection drug user	�	�	�	�
(3) High on some substance	�	�	�	�

END SECTION E

HEALTH AND HEALTH CARE SERVICES

SECTION F

HIV AND TESTING SERVICES

NOTE: THIS SECTION SHOULD ONLY BE COMPLETED BY PARTICIPANTS IN HIV PROGRAMS

52. At any time during the past 12 months, were you offered an HIV test? An HIV test checks whether someone has the virus that causes AIDS.

Yes

No

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

53. Would you like to be tested for HIV?

� Yes [REFER TO HIV TESTING CENTER]

� No

� DECLINED

� DON’T KNOW/INFORMATION NOT AVAILABLE

54. Have you ever been tested for HIV?

Yes

No [SKIP TO QUESTION 56]

DECLINED [SKIP TO QUESTION 56]

DON’T KNOW/INFORMATION NOT AVAILABLE [SKIP TO QUESTION 56]

55a. If you have been tested for HIV, did you receive your test results?

Yes, I received my results

No, I did not receive my results [SKIP TO QUESTION 56]

DECLINED [SKIP TO QUESTION 56]

DON’T KNOW/INFORMATION NOT AVAILABLE [SKIP TO QUESTION 56]

55b. If you have been tested for HIV, what is your current status?

Negative/Non-Reactive [SKIP TO QUESTION 56]

Positive/Reactive

Invalid/Indeterminate [SKIP TO QUESTION 56]

� DECLINED [SKIP TO QUESTION 56]

� DON’T KNOW/INFORMATION NOT AVAILABLE [SKIP TO QUESTION 56]

55c. If your HIV test was Positive/Reactive, did you receive a confirmatory test?

Yes

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE

56. Have you ever been tested for Hepatitis B?

Yes

No [SKIP TO QUESTION 58]

DECLINED [SKIP TO QUESTION 58]

DON’T KNOW/INFORMATION NOT AVAILABLE [SKIP TO QUESTION 58]

SECTION F

HIV AND TESTING SERVICES (CONTINUED)

NOTE: THIS SECTION SHOULD ONLY BE COMPLETED BY HIV PROGRAMS

57a. If you have been tested for Hepatitis B, did you receive your test results?

Yes, I received my results

No, I did not receive my results [SKIP TO QUESTION 58]

DECLINED [SKIP TO QUESTION 58]

DON’T KNOW/INFORMATION NOT AVAILABLE [SKIP TO QUESTION 58]

57b. If you have been tested for Hepatitis B, what was your test result?

Negative/Non-Reactive [SKIP TO QUESTION 58]

Positive/Reactive

Invalid/Indeterminate [SKIP TO QUESTION 58]

� DECLINED [SKIP TO QUESTION 58]

� DON’T KNOW/INFORMATION NOT AVAILABLE [SKIP TO QUESTION 58]

57c. If your Hepatitis B test was Positive/Reactive, did you receive a confirmatory test?

Yes

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE

58. Have you ever been tested for Hepatitis C?

Yes

No [STOP HERE; THE DATA COLLECTION IS COMPLETE]

DECLINED [STOP HERE; DATA COLLECTION IS COMPLETE]

DON’T KNOW/INFORMATION NOT AVAILABLE [STOP HERE; DATA COLLECTION IS COMPLETE]

59a. If you have been tested for Hepatitis C, did you receive your test results?

Yes, I received my results

No, I did not receive my results [STOP HERE; THE DATA COLLECTION IS COMPLETE]

DECLINED [STOP HERE; THE DATA COLLECTION IS COMPLETE]

DON’T KNOW/INFORMATION NOT AVAILABLE [STOP HERE; THE DATA COLLECTION IS COMPLETE]

59b. If you have been tested for Hepatitis C, what was your test result?

Negative/Non-Reactive [STOP HERE; DATA COLLECTION IS COMPLETE]

Positive/Reactive

Invalid/Indeterminate [STOP HERE; DATA COLLECTION IS COMPLETE]

� DECLINED [STOP HERE; DATA COLLECTION IS COMPLETE]

� DON’T KNOW/INFORMATION NOT AVAILABLE [STOP HERE; DATA COLLECTION IS COMPLETE]

SECTION F

HIV AND TESTING SERVICES (CONTINUED)

NOTE: THIS SECTION SHOULD ONLY BE COMPLETED BY HIV PROGRAMS

59c. If your Hepatitis C test was Positive/Reactive, did you receive a confirmatory test?

• Yes [STOP HERE; DATA COLLECTION IS COMPLETE]

• No [STOP HERE; DATA COLLECTION IS COMPLETE]

� DECLINED [STOP HERE; DATA COLLECTION IS COMPLETE]

� DON’T KNOW/INFORMATION NOT AVAILABLE [STOP HERE; DATA COLLECTION IS COMPLETE]

END SECTION F

HIV AND TESTING SERVICES