Outcome Baseline via Social Media

Attachment 1: lgbt young adult Baseline Instrument

Form Approved

OMB No. XXXX-xxxx

Exp. Date xx/xx/xxxx

Research and Evaluation Survey for the Public Education Campaign on Tobacco among Lesbian Gay Bisexual Transgender (LGBT) (RESPECT)

Subjects for Questionnaire:
Section AA: Informed Consent

Section A: Demographic Items

Section B: Tobacco Use Behavior

Section C: Tobacco Use Intentions and Self-Efficacy

Section D: Cessation (Intention, Behavior, Motivation)

Section E: Attitudes, Beliefs & Risk Perceptions, Social Norm

Section F: Media Use and Awareness

Section G: Environment

Section H: LGBT Identity and Community

Notes: LGBT stands for Lesbian Gay Bisexual Transgender

The “Prefer not to answer” option will be available for all questions; however, it will not be visible on the screen. Rather respondents will have the option of continuing to the next question without answering the current question. If they do, they will be prompted to answer the question they skipped and “Prefer not to answer” will appear as an option.

Section AA: Informed consent

AA1. [THE INFORMED CONSENT TEXT WILL BE INSERTED HERE.]

Section A: Demographic Items

The first part of the survey asks you some general questions about yourself.

A1. What is your date of birth? (mm-dd-yyyy)?

A2. Are you Hispanic, Latino/a, or of Spanish origin?

₁ No, not of Hispanic, Latino/a, or Spanish origin

₂ Yes, Mexican American, Chicano/a

₃ Yes, Puerto Rican

₄ Yes, Cuban

₅ Yes, another Hispanic, Latino/a, or Spanish origin

₉ Prefer not to answer

A3. What race or races do you consider yourself to be? (You can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER or YOU MAY SKIP THIS QUESTION)

	1 Yes	2 No	9 Prefer Not to Answer
A3_1. American Indian or Alaska Native	1	2	9
A3_2. Asian	1	2	9
A3_3. Black or African American	1	2	9
A3_4. Native Hawaiian or Other Pacific Islander	1	2	9
A3_5. White	1	2	9
A3_6. Other	1	2	9
A3_7. Prefer not to answer

A4. Which best describes your current job or paid employment status?

₁ Work full-time at least 35 hours per week

₂ Work part-time 15 to 34 hours per week

₃ Work part-time less than 15 hours per week

₄ I don't currently work for pay

₅ Don’t know

₉ Prefer not to answer

A5. What is the highest grade or level of school you have completed?

₁ Less than high school

₂ Some high school, no diploma

₃ GED

₄ High school graduate—diploma

₅ Some college but no degree

₆ Associate degree—occupational/vocational

₇ Associate degree—academic program

₈ Bachelor’s degree (ex: BA, AB, BS)

₉ Master’s degree (ex: MA, MS, MEng, Med, MSW)

₁₀ Professional school degree (ex: MD, DDS, DVM, JD)

₁₁ Doctorate degree (ex: PhD, EdD)

₁₂ Don’t know

₉₉ Prefer not to answer

A6. Are you currently enrolled in a degree program?

₁ Yes

₂ No

₃ Don’t know

₉ Prefer not to answer

A7. Which of the following categories best describes your total household income in the past 12 months?

This is the total income before taxes of all persons in your household combined. Please include money from jobs, relatives, pensions, dividends, interest, social security payments or retirement benefits, net income from business, farm or rent, and any other money received by household members.

₁ Less than $10,000

₂ $10,000 to $14,999

₃ $15,000 to $24,999

₄ $25,000 to $34,999

₅ $35,000 to $49,999

₆ $50,000 to $74,999

₇ $75,000 to $99,999

₈ $100,000 to $149,999

₉ $150,000 to $199,999

₁₀ $200,000 or more

₁₁ Don’t know

₉₉ Prefer not to answer

Section B: Tobacco Use Behavior

The next section asks about your experiences with tobacco products.

Cigarette Use

B1. Have you ever tried cigarette smoking, even one or two puffs?

₁ Yes

₂ No

₉ Prefer not to answer

[IF B1=1 or 9, ASK B2. IF B1=2, ASK B9]

B2. During the past 30 days, on how many days did you smoke cigarettes?

|_|_| days [RANGE: 0-30, 99]

[PN: IF RESPONDENT DOESN’T ANSWER 0-30, FILL WITH 99]

[IF B2=1 to 30, ASK B3, IF B2= 0 skip to B4]

B3. During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day?

₁ Fewer than 5 cigarettes

₂ 5-9 cigarettes

₃ 10 cigarettes (1/2 a pack)

₄ 11-19 cigarettes (more than 1/2 pack but less than 1 pack)

₅ 20 cigarettes (1 pack)

₆ 30 cigarettes (1 ½ packs)

₇ 40 cigarettes (2 packs)

₈ More than 40 cigarettes (more than 2 packs)

₉ Prefer not to answer

B4. On the days that you smoke, how soon after you wake up do you have your first cigarette? Would you say…

₁ Within 5 minutes

₂ 6-30 minutes

₃ 31-60 minutes

₄ After 60 minutes

₉ Prefer not to answer

B5. Do you consider yourself a smoker?

₁ Yes

₂ No

₉ Prefer not to answer

B6. Do you consider yourself a social smoker?

₁ Yes

₂ No

₉ Prefer not to answer

B7. About how many cigarettes have you smoked in your entire life? Your best guess is fine.

₁ 1 or more puffs but never a whole cigarette

₂ 1 cigarette

₃ 2 to 5 cigarettes

₄ 6 to 15 cigarettes (about 1/2 a pack total)

₅ 16 to 25 cigarettes (about 1 pack total)

₆ 26 to 99 cigarettes (more than 1 pack, but less than 5 packs)

₇ 100 or more cigarettes (5 or more packs)

₉ Prefer not to answer

B8. About how long has it been since you last smoked cigarettes?

₁ More than 30 days ago but within the past 3 months

₂ More than 3 months ago but within the past 12 months

₃ More than 12 months ago but within the past 3 years

₄ More than 3 years ago

₉ Prefer not to answer

B9. Have you ever used smokeless tobacco, such as chewing tobacco, snuff, snus (rhymes with goose) or dip, such as Copenhagen, Skoal, Grizzly, Kodiak, and Red Seal even just a small amount?

₁ Yes

₂ No

₉ Prefer not to answer

[IF B9=1, ASK B10]

B10. During the past 30 days, on how many days did you use chewing tobacco, snuff, snus or dip?

₁ 0 days

₂ 1 or 2 days

₃ 3 to 5 days

₄ 6 to 9 days

₅ 10 to 19 days

₆ 20 to 29 days or

₇ All 30 days

₉ Prefer not to answer

B11. Have you ever smoked cigars, cigarillos, or little cigars such as Swisher Sweets, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s, even one or two puffs?

₁ Yes

₂ No

₉ Prefer not to answer

[IF B11=1, ASK B12]

B12. During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars such as Swisher Sweets, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s?

₁ 0 days

₂ 1 or 2 days

₃ 3 to 5 days

₄ 6 to 9 days

₅ 10 to 19 days

₆ 20 to 29 days or

₇ All 30 days

₉ Prefer not to answer

B13. Have you ever tried smoking tobacco out of a water pipe (also called “hookah”)?

₁ Yes

₂ No

₉ Prefer not to answer

[IF B13=1, ASK B14]

B14. During the past 30 days, on how many days did you smoke tobacco out of a water pipe (also called “hookah”)?

₁ 0 days

₂ 1 or 2 days

₃ 3 to 5 days

₄ 6 to 9 days

₅ 10 to 19 days

₆ 20 to 29 days or

₇ All 30 days

₉ Prefer not to answer

B 15. These are examples of electronic cigarettes, also called “e-cigarettes”, “e-cigs”, “vapor pens”, or “e-hookahs”. Electronic cigarettes sometimes look like regular cigarettes, but run on a battery and produce vapor instead of smoke. Have you ever tried electronic cigarettes, even one or two puffs?

1 Yes

₂ No

₉ Prefer not to answer

[IF B15=1, ASK B16]

B16. During the past 30 days, on how many days did you use electronic cigarettes, also called “e-cigarettes”, “e-cigs”, “vapor pens”, or “e-hookahs”?

₁ 0 days

₂ 1 or 2 days

₃ 3 to 5 days

₄ 6 to 9 days

₅ 10 to 19 days

₆ 20 to 29 days or

₇ All 30 days

₉ Prefer not to answer

B17. During the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage?

₁ 0 days

₂ 1 or 2 days

₃ 3 to 5 days

₄ 6 to 9 days

₅ 10 to 19 days

₆ 20 to 29 days

₇ All 30 days

₉ Prefer not to answer

[Display Section C only if B1= 2 (never smokers)]

Section C: Tobacco Use Intentions and Self-Efficacy

C1. Thinking about the future…

		1 Definitely Yes	2 Probably Yes	3 Probably Not	4 Definitely Not	9 Prefer Not to Answer
C1_1.	Do you think that you will try a cigarette soon?	1	2	3	4	9
C1_2.	Do you think you will smoke a cigarette at any time in the next year?	1	2	3	4	9
C1_3.	If one of your best friends were to offer you a cigarette, would you smoke it?	1	2	3	4	9

C2. How sure are you that, if you really wanted to, you could avoid smoking cigarettes if…

[RANDOMIZE C2_1-C2_4]

	1 Not at all sure	2 Slightly sure	3 Somewhat sure	4 Mostly sure	5 Completely sure	9 Prefer Not to Answer
C2_1. You are at a party, bar or club?	1	2	3	4	5	9
C2_2. You are in a place where most people are smoking?	1	2	3	4	5	9
C2_2. Someone you know offers it?	1	2	3	4	5	9
C2_3. Someone you want to get to know offers it?	1	2	3	4	5	9
C2_4. Someone offers it to take a break?	1	2	3	4	5	9

Section D: Cessation (Intention, Behavior, Motivation)

Cigarette Use [Ask if B2=1 to 30]

D1. How much do you want to stop smoking for good? Would you say…?

₁ Not at all

₂ A little

₃ Somewhat

₄ A lot

₉ Prefer not to answer

D2. How much do you think your health would improve if you were to stop smoking for good?

₁ Not at all

₂ A little

₃ Somewhat

₄ A lot

₉ Prefer not to answer

D3. How worried are you that smoking will damage your health in the future?

₁ Not at all worried

₂ A little worried

₃ Somewhat worried

₄ Very worried

₉ Prefer not to answer

D4. How worried are you that smoking will damage your physical appearance or attractiveness?

₁ Not at all worried

₂ A little worried

₃ Somewhat worried

₄ Very worried

₉ Prefer not to answer

[Ask ALL]

Section E: Attitudes, Beliefs & Risk Perceptions, Social Norms

The next set of questions asks for your opinions on cigarette use and other tobacco products.

Attitude

E1. How much do you agree or disagree with the following statements about people who are tobacco-free?

[RANDOMIZE ALL ROWS]

		1 Strongly Disagree	2 Disagree	3 Neither Agree or Disagree (Neutral)	4 Agree	5 Strongly Agree	9 Prefer Not to Answer
E1_1.	People who are tobacco-free are confident.	1	2	3	4	5	9
E1_2.	People who are tobacco-free are trendsetting.	1	2	3	4	5	9
E1_3.	People who are tobacco-free are happy.	1	2	3	4	5	9
E1_4.	People who are tobacco-free are judgmental.	1	2	3	4	5	9
E1_5.	People who are tobacco-free are attractive.	1	2	3	4	5	9
E1_6.	People who are tobacco-free are basic.	1	2	3	4	5	9
E1_7.	People who are tobacco-free are boring.	1	2	3	4	5	9
E1_8.	People who are tobacco-free are predictable.	1	2	3	4	5	9

E2. Smoking cigarettes is… (pick one)

[RANDOMIZE E2_1-E2_2]

E2_1.	Bad								Good
E2_2.	Unenjoyable								Enjoyable

E3A. How much do you agree or disagree with the following statements?

[ASK E3A ONLY if B1= 2 (never smokers) OR B3= 0 (current non-smokers)

AND B9=2 (never smokeless users) OR B10= 0 (current smokeless non-users)

AND B11= 2 (never cigarillo users) OR B12= 0 (current cigarillo non-users)

AND B13= 2 (never hookah users) OR B14= 0 (current hookah non-users)

AND B15= 2 (never e-cigarette users) OR B16= 0 (current e-cigarette non-users]

ELSE SKIP to E3B (current tobacco users)]

[RANDOMIZE E3A_1-E3A_5]

		1 Strongly Disagree	2 Disagree	3 Neither Agree or Disagree (Neutral)	4 Agree	5 Strongly Agree	9 Prefer Not to Answer
E3A_1.	I am proud to live tobacco-free.	1	2	3	4	5	9
E3A_2.	Living tobacco-free is important to me.	1	2	3	4	5	9
E3A_3.	Tobacco use is harmful to the LGBT community.	1	2	3	4	5	9
E3A_4.	Being tobacco free when I go out makes me feel excluded.	1	2	3	4	5	9
E3A_5.	Using tobacco makes life harder.	1	2	3	4	5	9

SKIP TO E4

E3B. How much do you agree or disagree with the following statements?

[RANDOMIZE E3B_1-E3B_7]

		1 Strongly Disagree	2 Disagree	3 Neither Agree or Disagree (Neutral)	4 Agree	5 Strongly Agree	9 Prefer Not to Answer
E3B_1.	I would be proud to live tobacco-free.	1	2	3	4	5	9
E3B_2.	Living tobacco-free is important to me.	1	2	3	4	5	9
E3B_3.	If I lived tobacco-free I would be proud to tell other people.	1	2	3	4	5	9
E3B_4.	Using tobacco interferes with my life.	1	2	3	4	5	9
E3B_5.	Tobacco use is harmful to the LGBT community.	1	2	3	4	5	9
E3B_6.	If I was tobacco free I would feel excluded when I go out.	1	2	3	4	5	9
E3B_7.	Using tobacco makes life harder.	1	2	3	4	5	9

E4. How much do you agree or disagree with the following statements? If I smoke cigarettes every day, I will…

[RANDOMIZE ROWS]

		1 Strongly Disagree	2 Disagree	3 Neither Agree or Disagree (Neutral)	4 Agree	5 Strongly Agree	9 Prefer Not to Answer
E4_1.	Shorten my life	1	2	3	4	5	9
E4_2.	Be able to stop smoking when I want to	1	2	3	4	5	9
E4_3.	Damage my immune system	1	2	3	4	5	9
E4_4.	Turn off potential partners	1	2	3	4	5	9
E4_5.	Damage my teeth	1	2	3	4	5	9
E4_6.	Damage my skin	1	2	3	4	5	9
E4_7.	Develop lung cancer	1	2	3	4	5	9

Social Norms

E5. How many of your four closest friends…

		0 None	1 One	2 Two	3 Three	4 Four	9 Prefer Not to Answer
E5_1.	Smoke cigarettes?	0	1	2	3	4	9
E5_2.	Use a hookah or water pipe to smoke tobacco?	0	1	2	3	4	9
E5_3.	Use electronic cigarettes, also called “e-cigarettes”, “e-cigs”, “vapor pens”, or “e-hookahs”, Common brands are Blu, Njoy, Logic, Fin, Swisher, 21st Century Smoke, Vuse, Markten, V2 Ecigs, Nicotek or Vapin Plus.	0	1	2	3	4	9

E6. How many LGBT people who are your age...

		0 None	1 A few	2 Some	3 Most	4 All	9 Prefer Not to Answer
E6_1.	Smoke cigarettes?	0	1	2	3	4	9
E6_2.	Use a hookah or water pipe to smoke tobacco?	0	1	2	3	4	9
E6_3.	Use electronic cigarettes, also called “e-cigarettes”, “e-cigs”, “vapor pens”, or “e-hookahs”? Common brands are Blu, Njoy, Logic, Fin, Swisher, 21st Century Smoke, Vuse, Markten, V2 Ecigs, Nicotek or Vapin Plus.	0	1	2	3	4	9

E7. How do LGBT people your age feel about cigarette smoking? Would YOU say most LGBT people your age...

₂ Strongly disapprove

₃ Somewhat disapprove

₄ Neither approve nor disapprove

₄ Somewhat approve

₄ Strongly approve

₉ Prefer not to answer

E8. Compared to 3 months ago, people my age at LGBT bars, clubs and events are smoking...

₁ More often

₂ Less often

₃ About the same

₄ Not sure

₉ Prefer not to answer

Perceived Approval

E9. How much do you agree or disagree with the following statements?

[RANDOMIZE E9_1-E9_3]

		1 Strongly Disagree	2 Disagree	3 Neither Agree or Disagree (Neutral)	4 Agree	5 Strongly Agree	9 Prefer Not to Answer
E9_1.	According to my friends, it is very important for me to not smoke cigarettes.	1	2	3	4	5	9
E9_2.	According to most people who hang out where I hang out, it is very important for me to not smoke cigarettes.	1	2	3	4	5	9
E9_3.	According to people my age in LGBT communities it is very important for me to not smoke cigarettes.	1	2	3	4	5	9

E10. How much do you agree or disagree with the following statements? If I only smoke cigarettes on some days (for example, smoking only when I go out), I will…

[RANDOMIZE ROWS]

		1 Strongly Disagree	2 Disagree	3 Neither Agree or Disagree (Neutral)	4 Agree	5 Strongly Agree	9 Prefer Not to Answer
E10_1.	Shorten my life	1	2	3	4	5	9
E10_2.	Be able to stop smoking when I want to	1	2	3	4	5	9
E10_3.	Damage my immune system	1	2	3	4	5	9
E10_4.	Turn off potential partners	1	2	3	4	5	9
E10_5.	Damage my teeth	1	2	3	4	5	9
E10_6.	Damage my skin	1	2	3	4	5	9
E10_7.	Develop lung cancer	1	2	3	4	5	9

APPROVAL OF SMOKING

E11. This next set of questions asks about how willing or unwilling you are to do things with people who smoke cigarettes. Would you:

		1 Definitely Yes	2 Probably Yes	3 Probably Not	4 Definitely Not	9 Prefer Not to Answer
E11_1.	Go to a bar, club, party, concert or event where people are smoking cigarettes?	1	2	3	4	9
E11_2.	Hang out with someone who smokes cigarettes?	1	2	3	4	9
E11_3.	Dance with someone who smokes cigarettes?	1	2	3	4	9
E11_4.	Kiss someone who smokes cigarettes?	1	2	3	4	9
E11_5.	Date someone who smokes cigarettes?	1	2	3	4	9

E12. How much do you agree or disagree with the following statements about smoking cigarettes?

		1 Strongly Disagree	2 Disagree	3 Neither Agree or Disagree (Neutral)	4 Agree	5 Strongly Agree	9 Prefer Not to Answer
E12_1.	It is safe for me to smoke for only a year or two, as long as I quit after that.	1	2	3	4	5	9
E12_2.	If I started to smoke occasionally I would not become addicted.	1	2	3	4	5	9
E12_3.	Smoking cigarettes helps people relieve stress.	1	2	3	4	5	9
E12_4.	Cigarette ingredients are harmful.	1	2	3	4	5	9
E12_5.	Cigarette ingredients are dangerous.	1	2	3	4	5	9
E12_6.	Smoking is a way to show my identity to others.	1	2	3	4	5	9
E12_7.	Smoking cigarettes can help keep your weight down.	1	2	3	4	5	9
E12_8.	Smoking can cause damage to nearly every part of your body.	1	2	3	4	5	9
E12_9.	Smoking weakens your immune system.	1	2	3	4	5	9

Section F: Media Use and Awareness

Next, we’d like to ask you about your use of TV and other media.

F1. How often do you…

	1 Several times a day	2 About Once a Day	3 3-5 days a week	4 1-2 days a week	5 Every few weeks	6 Less often	7 Never	9 Prefer Not to Answer
F1_1. Watch TV shows or movies on any platform including a TV set, a computer, laptop or tablet, a smartphone or an iPod or MP3 player?	1	2	3	4	5	6	7	9
F1_2. Watch videos on YouTube?	1	2	3	4	5	6	7	9
F1_3. Listen to streaming radio?	1	2	3	4	5	6	7	9

F2. Thinking about the social networking sites you use... About how often do you visit or use the following…

[RANDOMIZE ALL]

	1 Several times a day	2 About Once a Day	3 3-5 days a week	4 1-2 days a week	5 Every few weeks	6 Less often	7 Never	9 Prefer Not to Answer
F2_1. Facebook	1	2	3	4	5	6	7	9
F2_2. Instagram	1	2	3	4	5	6	7	9
F2_3. Twitter	1	2	3	4	5	6	7	9
F2_4. Tumblr	1	2	3	4	5	6	7	9
F2_5. Snapchat	1	2	3	4	5	6	7	9

F3. Thinking about the following websites... About how often do you visit or use the following…

[RANDOMIZE ALL]

	1 Several times a day	2 About Once a Day	3 3-5 days a week	4 1-2 days a week	5 Every few weeks	6 Less often	7 Never	9 Prefer Not to Answer
F3_1. Queerty http://www.queerty.com/	1	2	3	4	5	6	7	9
F3_2. Logo TV http://www.logotv.com/	1	2	3	4	5	6	7	9
F3_3. Out http://www.out.com/	1	2	3	4	5	6	7	9
F3_4. Autostraddle http://www.autostraddle.com/	1	2	3	4	5	6	7	9
F3_5. After Ellen http://www.afterellen.com/	1	2	3	4	5	6	7	9
F3_6. Gay.com http://www.gay.com/	1	2	3	4	5	6	7	9

F4. How often do you go to concerts, live shows, or other events at a store, local stage, community center, or music venue?

₁ Once a week or more often

₂ One or two times a month

₃ Once every two or three months

₄ One or two times a year

₅ I do not attend concerts, live shows, or other events

₉ Prefer not to answer

F5. In the past 30 days, on how many days did you go to an LGBT party, night, bar, club, or event?

₁ 0 days

₂ 1-3 days

₃ 4-6 days

₄ 7 or more days

₅ Don’t remember how many days

₉ Prefer not to answer

F6. How many LGBT celebrities, athletes, musicians, or artists do you follow on social media (e.g. Laverne Cox, Tegan & Sara, Ruby Rose, Angel Haze)?

₁ 0

₂ 1-2

₃ 3-4

₄ 5 or more

₉ Prefer not to answer

Section G: Environment

The next section asks some questions about your household and peers.

G1. Other than you, has anyone who lives with you used any of the following during the past 30 days…? (You can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)

₁ cigarettes

₂ cigars, cigarillos, or little cigars such as Swisher Sweets, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s

₃ tobacco out of a water pipe (also called “hookah”)

₄ No, no one who lives with me has used any form of tobacco during the past 30 days

₉ Prefer not to answer

G2. How often do you attend church or religious services? Would you say…

₁ Never

₂ Less than once a month

₃ About once a month

₄ About 2 or 3 times a month

₅ Once a week

₆ More than once a week

₉ Prefer not to answer

Please tell us if you strongly agree, agree, disagree, or strongly disagree with the following statements.

G3. I would like to explore strange places. Would you say you…

₁ Strongly Disagree

₂ Disagree

₃ Neither agree nor disagree (neutral)

₄ Agree

₅ Strongly Agree

₉ Prefer not to answer

G4. I like to do frightening things. Would you say you…

₁ Strongly Disagree

₂ Disagree

₃ Neither agree nor disagree (neutral)

₄ Agree

₅ Strongly Agree

₉ Prefer not to answer

G5. I like new and exciting experiences, even if I have to break the rules. Would you say you…

₁ Strongly Disagree

₂ Disagree

₃ Neither agree nor disagree (neutral)

₄ Agree

₅ Strongly Agree

₉ Prefer not to answer

G6. I prefer friends who are exciting and unpredictable. Would you say you…

₁ Strongly Disagree

₂ Disagree

₃ Neither agree nor disagree (neutral)

₄ Agree

₅ Strongly Agree

₉ Prefer not to answer

G7. Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

_____ Number of days

₂ None

₃ Don’t know

₉ Prefer not to answer

G8. In the last month, how often have you

		0 Never	1 Almost never	2 Sometimes	3 Fairly often	4 Very often	9 Prefer Not to Answer
G8_1.	Felt that you were unable to control the important things in your life.	1	2	3	4	5	9
G8_2.	Felt confident about your ability to handle your personal problems.	1	2	3	4	5	9
G8_3.	Felt that things were going your way.	1	2	3	4	5	9
G8_4.	Felt difficulties were piling up so high that you could not overcome them.	1	2	3	4	5	9

Section H: LGBT Identity and Community

Discrimination

H1. Have you ever experienced discrimination, been prevented from doing something, or been hassled or made to feel inferior in any of the following seven situations because of your sexual identity (lesbian, gay, bisexual, transgender)?

		1 Yes	2 No	9 Prefer not to answer
H1_1.	In your family	1	2	9
H1_2.	At school	1	2	9
H1_3.	Getting a job	1	2	9
H1_4.	At work	1	2	9
H1_5.	At home	1	2	9
H1_6.	Getting medical care	1	2	9
H1_7	On the street or in a public setting	1	2	9

LGBT Community Involvement

H2_1. Have you ever attended a LGBT pride event?

₁ Yes

₂ No

₉ Prefer not to answer

[IF H2_1= 1 SKIP TO H3]

H2_2. Have you attended a LGBT pride event in the past 12 months?

₁ Yes

₂ No

₉ Prefer not to answer

LGBT Identity Development

H3. For each of the following questions, please mark the response that best

indicates your current experience as an LGBT person. Please be as honest as possible: Indicate how you really feel now, not how you think you should feel. There is no need to think too much about any one question. Answer each question according to your initial reaction and then move on to the next.

		1 Strongly Disagree	2 Disagree	3 Neither Agree or Disagree (Neutral)	4 Agree	5 Strongly Agree	9 Prefer Not to Answer
H3_1.	I am glad to be an LGBT person.	1	2	3	4	5	9
H3_2.	My sexual identity is an insignificant part of who I am.	1	2	3	4	5	9
H3_3.	I’m proud to be part of the LGBT community.	1	2	3	4	5	9
H3_4.	My sexual identity is a central part of my identity.	1	2	3	4	5	9
H3_5.	To understand who I am as a person, you have to know that I’m LGBT.	1	2	3	4	5	9
H3_6.	Being an LGBT person is a very important aspect of my life.	1	2	3	4	5	9
H3_7.	I believe being LGBT is an important part of me.	1	2	3	4	5	9
H3_8.	I am proud to be LGBT.	1	2	3	4	5	9
H3_9.	I feel part of the LGBT community	1	2	3	4	5	9
H3_10.	I feel accepted by the LGBT community”	1	2	3	4	5	9

Thank you for taking time to complete this survey.

OMB No: 0910-XXXX Expiration Date: XX/XX/XXXX

Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 30 minutes per response. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to [email protected]

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