Male Enrollment Questionnaire

STUDY ID: ___________________

ZEN COLOMBIA

Male Enrollment Questionnaire

Study site: _______________________________________________________

First, I will start with some questions about you.

1. What is your birthdate? __ __/__ __ __ /__ __ __ __ ₇₇ Don’t know ₈₈ Refused

D D M M M Y Y Y Y

2. What is your ethnicity? (Choose one only).

₁ Mestiza ₂ White ₃ Afrocolombian ₄ Indigenous ₅ Asian ₆ Multi-ethnic ₇ Other

₇₇ Don’t know ₈₈ Refused

3. What is the highest level of education that you have completed?

₁ Less than primary ₂ Primary ₃ Secondary ₄ Technical ₅ University or more

₇₇ Don’t know ₈₈ Refused

4. In the past 3 months, have you traveled to another province or country?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

If yes: Where did you travel?

a. Place: _________________________ # days: __________

b. Place: _________________________ # days: __________

c. Place: _________________________ # days: __________

The next questions are about mosquito bites.

5. In the past 7 days, how many mosquito bites did you get?

₀ None ₁ Less than 20 ₂ 20 or more, or too many to count

₇₇ Don’t know ₈₈ Refused

6. On average, how many hours per day do you spend outside?

_______ hours/day ₇₇ Don’t know ₈₈ Refused

7. In the past 7 days, how often have you…

	Never	Some of the time	Most of the time	Not applicable	Don’t know	Refused
Worn long pants that covered your legs
Worn shirts or jackets with long sleeves that covered your arms
Worn permethrin-treated clothing
Worn shoes with socks
Used mosquito repellant

8. In the past 7 days, when you were inside your home, how often was the air conditioner running?

₃ Never ₂ Some of the time ₁ Most of the time ₀ I don’t have air conditioning

₇₇ Don’t know ₈₈ Refused

9. Does your home have intact screens on all windows and doors that prevent mosquitos from entering?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused ₁ Not applicable

The next questions are about Zika virus.

10. Do you think it’s possible to get Zika virus in your community?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

11. Do you know anyone who has had Zika virus?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

12. How worried are you about getting Zika virus?

₃ Very worried

₂ Somewhat worried

₁ Not at all worried

₀ I have already had Zika virus

₇₇ Don’t know

₈₈ Refused

13. Does everybody with Zika virus have symptoms?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

14. How likely is it that someone can get Zika in the following ways? Say “very likely”, “somewhat likely”, or “impossible” to each statement.

	Very likely	Somewhat likely	Impossible	Don’t know	Refused
Being bitten by an infected mosquito
Having vaginal sex with a person who has Zika without using a condom
Kissing someone who has Zika
Shaking hands with someone who has Zika
An infected person coughs or sneezes on you
From a blood transfusion if the blood has Zika in it
A baby can get Zika before it is born if its mother has Zika during pregnancy

15. How likely is it that the baby of a pregnant woman with Zika will have…? (Say “very likely”, “somewhat likely”, or “impossible” to each statement).

	Very likely	Somewhat likely	Impossible	Don’t know/Refused
Microcephaly (a small sized head)
Other birth defects

16. In the past 3 months, have you had symptoms of Zika virus? Symptoms of Zika virus means being sick with 2 or more of fever, rash, red eyes, and joint pain that are not explained by other causes.

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

If yes: When? _____ / _______

mmm yyyy

17. Has a doctor or healthcare provider ever told you that you might have Zika virus?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

If yes: When? _____ / _______

mmm yyyy

Next I’ll ask you some questions about your home, community, and environment.

18. Where do you usually get your drinking water? (Select all that apply.)

₇ Public or private water utility

₆ Well

₅ Cistern or tank

₄ Bottled water

₃ Lake, river, or other natural source

₂ Minimo vital de agua potable (“free basic water”)

₁ Water is provided to you, but the source is unknown

₀ Another water source

₇₇ Don’t know

₈₈ Refused

19. In the past 3 months, have you worked at a job? Include jobs in which you don’t have a formal employer, such as selling goods or providing services.

₀ No ₁ Yes ₇₇ Don’t know ₈₈ Refused

If yes: Have any of your jobs in the past 3 months involved:

Battery manufacturing or battery recycling	0 No 1 Yes 77 Don’t know 88 Refused
Electronic waste recycling	0 No 1 Yes 77 Don’t know 88 Refused
Gold mining or gold processing	0 No 1 Yes 77 Don’t know 88 Refused
A job in which you or other people around you use lead	0 No 1 Yes 77 Don’t know 88 Refused
A job in which you or other people around you use mercury	0 No 1 Yes 77 Don’t know 88 Refused

20. In the past 3 months, have you used any pesticides, insecticides, or rat poison in or around your home?

₀ No ₁ Yes ₇₇ Don’t know ₈₈ Refused

Now I’ll ask you about your health.

21. Have you ever had…?

Yellow fever	1 Yes 0 No 77 Don’t know 88 Refused
Dengue	1 Yes 0 No 77 Don’t know 88 Refused
Chikungunya	1 Yes 0 No 77 Don’t know 88 Refused

22. Have you ever been vaccinated for…?

Yellow fever	1 Yes 0 No 77 Don’t know 88 Refused
Dengue	1 Yes 0 No 77 Don’t know 88 Refused

23. In the past 3 months, have you smoked cigarettes?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

These next few questions are about your recent sexual experiences.

24. In the past 3 months, how many different women have you had sex with?

₀ None ₁ 1 ₂ 2 ₃ 3 or more ₇₇ Don’t know ₈₈ Refused

If None: go to question 30.

25. In the past 3 months, how often have you had vaginal sex with a woman? Choose the best answer.

₁ Once a day or more

₂ Two or more times a week

₃ Once a week

₄ A few times a month

₅ Once a month

₆ Less than once a month

₇₇ Don’t know

₈₈ Refused

26. When you had sex in the past 3 months, how often have you used a condom?

₂ Always ₁ Sometimes ₀ Never ₇₇ Don’t know ₈₈ Refused

27. Since you found out that your partner was pregnant, have you changed how often you use condoms during sex with your partner?

₁ Yes, I use them more often

₂ Yes, I use them less often

₃ No, I haven’t changed how often I use condoms

₀ We haven’t had sex regularly

₇₇ Don’t know

₈₈ Refused

28. In the past 3 months, have you…?

Received oral sex from someone	1 Yes 0 No 77 Don’t know 88 Refused
Performed oral sex on someone	1 Yes 0 No 77 Don’t know 88 Refused
Had anal sex	1 Yes 0 No 77 Don’t know 88 Refused

29. Are you circumcised?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

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