Sample Survey Questions

Form Approved

OMB No. 0920-0920

Exp. Date XX-XX-XXX

Data Collection Through Web Based Surveys for Evaluating Act Against AIDS Social Marketing Campaign Phases Targeting Consumers

Attachment 3

Potential AAA Survey Items:

Campaign Message Effectiveness & Exposure and Reach

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-0920)

AAA Campaign Message Effectiveness Sample Items

The following questions are about a [radio/TV/billboard] ad you [saw/heard] [earlier], entitled “_________________.” To refresh your memory of this ad, we would like to play/show it for you again.

[PLAY AUDIO 1/SHOW]:

1. Please indicate how much you agree or disagree with the following statements about this ad.

	Strongly agree	Agree	Disagree	Strongly disagree	Don’t know	Refuse to answer
Overall, I liked this ad.	1	2	3	4	5	6
b. I liked the people in this ad.	1	2	3	4	5	6
c. I liked the voices in this ad.	1	2	3	4	5	6
d. This ad was easy to listen to (to read).	1	2	3	4	5	6
e. I learned something new by listening to (by reading) this ad.	1	2	3	4	5	6
f. I was interested in listening to (reading) this ad.	1	2	3	4	5	6
g. This ad was made (written) for a person like me.	1	2	3	4	5	6
h. This ad was easy to understand.	1	2	3	4	5	6
I liked the sound effects in this ad.	1	2	3	4	5	6
j. I would look at (read) this ad if I saw it.	1	2	3	4	5	6
k. I am interested in this ad’s topic.	1	2	3	4	5	6
l. I like the way this ad looks.	1	2	3	4	5	6
m. I liked the colors in this ad.	1	2	3	4	5	6
n. I trust the information in this ad.	1	2	3	4	5	6
o. I can do what this ad suggests.	1	2	3	4	5	6
p. I will do what this ad suggests.	1	2	3	4	5	6
q. I trust the information in this ad.	1	2	3	4	5	6
r. This ad was believable.	1	2	3	4	5	6

2. Please indicate how much you agree or disagree with the following statements about the (INSERT format—television ad, radio ad, print ad, brochure, video, etc.).

	Strongly agree	Agree	Disagree	Strongly disagree	Don’t know	Refuse to answer
This [INSERT format] was convincing.	1	2	3	4	5	6
This [INSERT format] said something important to me.	1	2	3	4	5	6
I liked this [INSERT format] overall.	1	2	3	4	5	6
This [INSERT format] grabbed my attention.	1	2	3	4	5	6
This [INSERT format] told me something I didn’t already know.	1	2	3	4	5	6
This [INSERT format] would be helpful in convincing my friends to [INSERT behavior]	1	2	3	4	5	6
g. This ad made me feel confident that I could [INSERT behavior]	1	2	3	4	5	6
This [INSERT format] gave me good reasons to get an HIV test.	1	2	3	4	5	6
This [INSERT format] was confusing.	1	2	3	4	5	6
This [INSERT format] spoke to me.	1	2	3	4	5	6
I do not like this [INSERT format].	1	2	3	4	5	6
I learned something new from [INSERT format].	1	2	3	4	5	6
Real people would act (talk/look) the way the person(s) in this ad [INSERT]	1	2	3	4	5	6
The person(s) in this ad were more similar to me than different.	1	2	3	4	5	6
I could relate to what the person(s) in this ad were going through.	1	2	3	4	5	6
I felt [INSERT emotion] while viewing (listening to) the ad.	1	2	3	4	5	6

3. Please rate the persuasiveness of the [INSERT format—print ad, video, etc.] you just saw. Be honest, how persuasive was it?

1. The message that I saw about [INSERT] was compelling

2. The message about [INSERT] was persuasive

3. The message was dumb

4. The message was weak

5. Don’t know

6. Refuse to answer

Potential AAA Exposure and Reach Sample Survey Items

1. During the past [INSERT TIME FRAME], have you seen or heard any advertising, campaigns, or messages about….

	Yes	No	Don’t know	Refuse to answer
Using drugs	1	2	3	4
Quitting smoking	1	2	3	4
Not starting to smoke	1	2	3	4
Getting an HIV test	1	2	3	4
Using condoms to prevent AIDS or sexually transmitted diseases	1	2	3	4
The importance of knowing whether you or your partner is HIV positive	1	2	3	4
Not using alcohol	1	2	3	4
Other [Specify:____________________________]	1	2	3	4

2. Have you ever seen or heard of any ads on/at [INSERT] called [or with the following themes or slogans]?

	Yes	No	Don’t know	Refuse to answer
a.[INSERT NAMES] EXAMPLE: Know HIV/AIDS	1	2	3	4
b. EXAMPLE: Rap it Up	1	2	3	4
c. EXAMPLE: Get tested. Get the results. Get on with your life.	1	2	3	4
d. EXAMPLE: With HIV, Knowledge Is Power	1	2	3	4
e. EXAMPLE: 9 ½ minutes	1	2	3	4

3. This is an ad in which [INSERT]. Have you ever seen [or heard] this ad?

1. Yes

2. No

3. Don’t know

4. Refuse to answer

4. In the last [INSERT TIME FRAME], about how often have you seen [or heard] HIV/AIDS-related ads on [INSERT MEDIUM]?

1. Not at all

2. Less than 1 time a month

3. 1 to 3 times a month

4. 1 to 3 times a week

5. Daily or almost daily

6. More than 1 time a day

7. Don’t know

8. Refuse to answer

5. In the last [INSERT TIME FRAME], how often have you noticed stories that dealt with HIV/AIDS among [INSERT GROUP]?

1. Not at all

2. Less than 1 time a month

3. 1 to 3 times a month

4. 1 to 3 times a week

5. Daily or almost daily

6. More than 1 time a day

7. Don’t know

8. Refuse to answer

6. In the last [INSERT TIME FRAME], about how often have you seen [or heard] HIV/AIDS-related ads in/on/at [INSERT]?

1. Not at all

2. Less than 1 time a month

3. 1 to 3 times a month

4. 1 to 3 times a week

5. Daily or almost daily

6. More than 1 time a day

7. Don’t know

8. Refuse to answer

7. In the last [INSERT TIME FRAME], how many times have you seen [or heard] this ad?

1. Not at all

2. Once

3. 1 to 5 times

4. 6 to 10 times

5. More than 10 times

7. Don’t know

8. Refuse to answer

8. Did you see or hear this ad yesterday?

1. Yes

2. No

3. Don’t know

4. Refuse to answer

9. Where did you see [or hear] this ad?

10. Ads that appear in separate boxes on Web pages are called banner ads. Have you ever seen this banner ad on a Web page? [Show banner ad.]

1. Yes

2. No

3. Don’t know

4. Refuse to answer

11. On what Web sites have you seen this ad?

12. Did you ever click on the banner ad to go to the linked Web site?

1. Yes

2. No

3. Don’t know

4. Refuse to answer

13. In the past [INSERT TIME FRAME] have you seen any materials for CDC’s _____ campaign?

1. Yes

2. No

3. Don’t know

4. Refuse to answer

14. Are you aware of any materials or campaigns specifically focused on _______?

1. Yes

2. No

3. Don’t know

4. Refuse to answer

15. If Yes: Please select the key messages/elements present in the materials.
[SELECT ALL THAT APPLY.]

1. A picture or graphic of _____________

2. Chart showing __________________

3. ________ logo/slogan

4. A list of frequently asked questions about…. patients living with HIV might ask about transmission

5. A checklist of ____________

6. Other [Specify: ]

7. Don’t know

8. Refuse to answer

17. Where did you hear about the campaign?

1. Saw poster in health care provider’s office

2. Heard about from health care provider

3. Received materials from doctor

4. Other [Specify: ]

5. Don’t know

6. Refuse to answer

18. Have you ever heard of the [INSERT CAMPAIGN]?

1. Yes

2. No

3. Don’t know

4. Refuse to answer

19. This is a campaign that encourages young adults to talk about HIV. Have you ever heard of this campaign?

1. Yes

2. No

3. Don’t know

4. Refuse to answer

20. We want to ask you about some brief messages that might or might not have appeared on social media sites, as part of ads encouraging people to talk about HIV. In recent months, have you seen or heard either of the following phrases?

1. INSERT PHRASE 1

1. Yes

2. No

3. Don’t know

4. Refuse to answer

2. INSERT PHRASE 2

1. Yes

2. No

3. Don’t know

4. Refuse to answer

Please tell us how much you agree or disagree with the following statement.

21. It is important to get tested for HIV so that people who test positive can start getting treated right away.

1. Strongly agree

2. Agree

3. Disagree

4. Strongly disagree

5. Don’t know

6. Refuse to answer

22. If you were to be tested for HIV, do you think it would make people you know think [ROTATE ORDER OF MORE/LESS: (less) of you, think (more) of you], or would it make no difference in how people you know think of you?

1. Less of you

2. More of you

3. Make no difference

4. Some less, some more

5. Don’t know

6. Refuse to answer

23. Do you plan to have a test for HIV in the next [INSERT TIME FRAME], not including blood donations?

1. Definitely yes

2. Probably yes

3. Probably not

4. Definitely not

5. Don’t know

6. Refuse to answer

24. How likely is it that you will get tested for HIV [INSERT TIME FRAME]?

1. Very likely

2. Somewhat likely

3. Neither likely or unlikely

4. Somewhat likely

5. Very unlikely

6. Don’t know

7. Refuse to answer

25. If a free test was available to see if you have HIV, would you take it?

1. Definitely yes

2. Probably yes

3. Probably not

4. Definitely not

5. Don’t know

6. Refuse to answer

26. How often do you think someone should get tested for HIV if they…

	Every 1–2 months	Every 3–6 months	Every 7–12 months	Every couple of years	Don’t know
a. Always have sex with a condom
b. Have had anal sex without a condom
c. Have a sex partner who is HIV positive
d. Have unprotected anal sex with a partner whose HIV status they don’t know
e. Have had more than one sex partner since their last HIV test
f. Exchange sex for drugs

27. On a scale from 1 to 6, where 1 is extremely bad and 6 is extremely good, how would you rate getting tested for HIV [INSERT TIME FRAME]?

	1	2	3	4	5	6
Extremely bad							Extremely good

28. On a scale from 1 to 6, where 1 is extremely harmful and 6 is extremely beneficial, how would you rate getting an HIV test [INSERT TIME FRAME]?

	1	2	3	4	5	6
Extremely harmful							Extremely beneficial

29. How sure are you that you could get an HIV test at least every 12 months if…

	Very sure I could not	Somewhat sure I could not	Slightly sure I could	Somewhat sure I could	Very sure I could
a. You wanted to get an HIV test at least every 12 months?
b. You could find a free testing site?
c. You had to travel far to find a free testing site?
d. You could get the results of your HIV test within 20 minutes?
e. You knew that your results would be kept private?

30. Please tell us how much you disagree or agree with each of the following statements: “Getting tested at least every 12 months…”

	Strongly disagree	Disagree	Neither disagree or agree	Agree	Strongly agree
a. Is expensive.
b. Reassures me that I can get into treatment early if I test positive.
c. Makes me feel like a ho.
d. Is inconvenient.
e. Allows me to have unprotected sex with partners who are HIV negative.