Survey screener

Formative Tools for Addressing HIV Prevention Preferences Among Adolescent Men Who Have Sex with Men (AMSM)

Attachment 1a AMSM Survey Screener

Form Approved

OMB No: 0920-0840

Exp. Date: 1/31/2019

Public reporting burden of this collection of information is estimated to average 5 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 (0920-0840)

Thank you for agreeing to participate in our study.

Please use the “Next” and “Back” buttons to navigate between the questions within the questionnaire. Do not use your browser buttons.

If you step away from your computer for an extended period of time, your session may time out and you will not be able to log back into the survey. Please try to complete the survey at one time so that you are able to retrieve your gift code.

Thank you for your help with this important survey about young people’s sexuality and health. We would like to start by asking you a few questions about yourself and how you view yourself in your own words.

1.	How old are you? [_ _]
	Prefer not to Answer

2.	What region of the United States do you live in?
	Northeast
	Southeast
	Midwest
	West
	Not in the United States
	Prefer not to Answer
	Don’t Know

<Programmer instructions: Please add a map to SC4 displaying the regions and contained states>

3.	Would you say you live in:
	A big city
	A small city
	The suburbs
	A rural place

4.	Are you currently in school?
	Yes
	No
	Don't Know
	Prefer not to Answer

Please indicate your race or ethnic background. Are you…?

5.	SELECT ONE Ethnicity:
	Hispanic or Latino
	Not Hispanic or Latino
	Don't Know
	Prefer not to Answer

6.	SELECT ONE OR MORE Race:
	White
	Black or African American
	American Indian or Alaska Native
	Native Hawaiian or Other Pacific Islander
	Asian
	Prefer not to answer…………………………………………………………………..
	Don’t know……………………………………………………………………………..

7.	What sex were you assigned at birth, on your original birth certificate?
	Male
	Female
	Prefer not to Answer
	Don’t Know

8.	How do you currently describe your gender? (Check the ONE that best applies to you)
	Male
	Female Genderqueer/Gender nonconforming
	Transgender female-to-male Transgender male-to-female Something else, please specify
	[PROGRAMMER NOTE: For questions #7 and 8, message will appear if the respondent enters a gender for Q8 that doesn't match what they entered for Q7. So if Male for Q7, then Female for Q8 (and vice versa), the message below appears. It should only appear if they select Male then Female or Female then Male. If they select No, they should return to the Q8 screen, if they select Yes, let them continue to the next question. Just to confirm, you were assigned {M/F} at birth and now describe yourself as {M/F} Is that correct?]
9.	People are different in their sexual attraction to other people. Which best describes your feelings? Are you…
	Only attracted to females
	Mostly attracted to females
	Equally attracted to females and males
	Mostly attracted to males
	Only attracted to males
	Not attracted to males or females……………………………………………………………………
	Don't Know
	Prefer not to Answer

10.	During your life, with whom have you had sexual contact? By sexual contact, we mean kissing, mutual masturbation, oral, anal, or vaginal sex. By oral sex, we mean putting your mouth on someone else’s genitals or when your partner does this to you. By anal sex, we mean when one person’s penis is inside their partner’s anus or rectum. By vaginal sex, we mean when one person’s penis is inside another partner’s vagina.
	I have never had sexual contact
	Females
	Males
	Females and males

11.	How would you describe yourself? (Check the ONE that best applies to you)
	Heterosexual/straight…………………………………………………………………………………….. Lesbian
	Gay
	Bisexual
	Queer
	Pansexual…………………………………………………………………………………………………………
	Asexual…………………………………………………………………………………………………………….
	Demisexual…………………………………………………………………………………………………….. Questioning/unsure
	Something else

11b.

[if something else] What do you mean by something else? [_________________________]

12.

[if selected option other than heterosexual/straight for Q11] At what age did you first believe yourself to be [AUTO FILL RESPONSE TO Q11/11b], even if you didn’t tell other people about it? [_ _]

13.	[if selected option other than heterosexual/straight for Q11] Have you ever told anyone that you are [AUTOFILL RESPONSE TO Q11/11b]?
	Yes
	No
	Don't Know
	Prefer not to Answer

<PROGRAMMER: There will be a trans and non-trans version of the questionnaire. The variable P_QUEX01 will be used to identify which questions are assigned to the non-trans version only (P_QUEX01=0) and to the trans version only (P_QUEX01=1). If there is no P_QUEX01 value, then the question will appear in both versions of the survey.

If SC8 (in screener)=Transgender OR (if SC7=Male AND SC8=Female) then P_QUEX01=1, Else P_QUEX01=0.

There will also be a color coded designation in this document for facilitated review. Trans only questions will be in green while non-trans only questions will be in blue. Those questions in both versions will be in gray.>

“NOT ELIGIBLE FOR THE SURVEY” SCREEN

Unfortunately, you are not eligible to participate in this survey.

Thank you for your interest.

<PROGRAMMER: Please provide an “exit the questionnaire” button.>

AMSM Screener-9