PHC Tailoring Questions - Att 7

Attachment 7

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Tailoring Questions

Positive Health Check

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-New)

DEM1 What sex were you assigned at birth, on your original birth certificate?

Male

Female

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DEM2 How do you describe your gender identity?

Male

Female

Male – to – Female transgender (MTF)

Female – to – Male transgender (FTM)

Other gender identity

Skip

DEM3 And how long ago did you find out that you have HIV?

Within the last 3 months

4 to 6 months ago

7 to 12 months ago

1 to 5 years ago

More than 5 years ago

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DEM4 Before today, had you been getting medical care for your HIV infection?

Yes

No

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MED Are you currently taking any HIV meds to treat your HIV infection?

Yes

No

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MEDHX Okay, have you ever taken any HIV meds in the past?

Yes

No

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MEDTalk Have you been talking to your doctor about starting HIV meds?

Yes

No

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ADH1 In the last 30 days, how good a job did you do at taking your HIV medicines in the way you were supposed to? Touch, or click on, the answer that best describes how good a job you did.

Very Poor

Poor

Fair

Good

Very Good

Excellent

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RIC1     Not counting any clinic visits you may have had in the past 7 days, when was the last time you saw your doctor or nurse for HIV medical care in a clinic?

within the past 2 months

3 to 4 months ago

5 to 6 months ago

7 to 12 months ago

Over 12 months ago

This is my first visit for HIV medical care

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RIC2 Now, thinking about the past 6 months, were there any times that you missed any HIV medical care appointment and it wasn’t rescheduled within a month?

Yes

No

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SEX1 Let’s take a moment to talk about your sex life.

With whom do you usually have sex?

Only men

Only women

Both men and women

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SEX2 In the past 2 months, with how many different people did you have vaginal or anal sex? Use the keyboard to type your answer.

_________ (range: 0- TBD)

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SEX3 And with how many of these people did you have vaginal or anal sex without you or your partner using a condom?

____________ (range: 0- number entered for SEX2)

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SEX4 Of these people, how many did you know to be HIV-positive at the time you had sex with them? Use the keyboard to type your answer.

_____________ (range: 0-number entered for SEX3)

Don’t want to answer

MTCT1 Now, I don’t know if this applies to you or not, but are you or your partner pregnant or planning to get pregnant in the near future?

Yes

No

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IDU1 I just have a final question about using drugs. In the past two months, have you injected any drugs that were not prescribed for you by your doctor?

Yes

No

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