ZEN Columbia - Male Partner Enrollment Questionnaire - E

STUDY ID: __________ -___-______________________ Form Approved

OMB No. 0920-XXXX

Date: __ __/__ __ __ /__ __ __ __ Exp. Date xx/xx/20xx

D D M M M Y Y Y Y

Staff Administered: ___________________________

MALE PARTNER Enrollment Questionnaire

City: _______________________________________________________

Clinic: _____________________________________________________

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 the highest level of education that you have completed?

₁ Less than primary ₂ Primary ₃ Secondary ₄ Technical ₅ University or more ₀ None

₇₇ Don’t know ₈₈ Refused

3. What type of health insurance do you have?

₁ Contributory ₂ Subsidized ₃ Not insured ₄ Specialized ₅ Exception

₆ Indeterminate / independent ₇₇ Don’t know ₈₈ Refused

4. What is the name of your health insurance provider?

Name: ___________________________________________ ₇₇ Don’t know ₈₈ Refused

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. In the past 7 days, how often have you done the following things? Response options include never, some of the time, or always.

	Never0	Some of the time1	Always2	Don’t know77	Refused88
Worn long pants that covered your legs
Worn shirts or jackets with long sleeves that covered your arms
Kept your ankles and feet completely covered
Used mosquito repellant

The next questions are about what you might have heard about Zika virus.

7. Do you think it’s possible for a person to get Zika virus in your community?

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

8. Do you think that everybody with Zika virus has symptoms?

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

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

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

Have you had Zika virus?

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

10. How worried have you been about getting Zika virus during your partner’s current pregnancy?

₃ Very worried ₂ Somewhat worried ₁ Not at all worried

₇₇ Don’t know ₈₈ Refused

11. Momentarily, I will give you a number of statements about Zika virus; we ask that you respond if you consider it to be “very likely”, “somewhat likely”, or “impossible” that Zika can be transmitted by any one of these means.

	Very likely2	Somewhat likely1	Impossible0	Don’t know77	Refused88
Being bitten by an infected mosquito
Having vaginal sex with a woman who has Zika without using a condom
Kissing someone on the mouth who has Zika
Shaking hands with someone who has Zika
Being coughed or sneezed on by someone who has Zika
Receiving a blood transfusion with Zika in it
Being in utero if a mother has Zika during pregnancy

12. Momentarily, I will give you a number of statements about the possible effects on a baby if their mother was infected with Zika during her pregnancy; we ask that you respond if you consider it to be “very likely”, “somewhat likely”, or “impossible” that a baby could be born with the following conditions:

	Very likely2	Somewhat likely1	Impossible0	Don’t know77	Refused88
Microcephaly (a small sized head)
Other birth defects
Intrauterine growth restriction (small baby)
Miscarriages/stillbirths

The next questions are about Zika symptoms you might have had.

13. 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

When?

__ __/ __ __ __ / __ __ __ __ ₇₇ Don’t know ₈₈ Refused

D D M M M Y Y Y Y

14. At any time, 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

When?

__ __/ __ __ __/ __ __ __ __ ₇₇ Don’t know ₈₈ Refused

D D M M M Y Y Y Y

Next I’ll ask you some questions about your job.

15. 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.

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

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

Battery manufacturing or battery recycling	1 Yes 0 No 77 Don’t know 88 Refused
Electronic waste recycling	1 Yes 0 No 77 Don’t know 88 Refused
Gold mining or gold processing	1 Yes 0 No 77 Don’t know 88 Refused
Other metal mining (for example, uranium, nickel, or cobalt)	1 Yes 0 No 77 Don’t know 88 Refused
A job in which you or your coworkers use lead	1 Yes 0 No 77 Don’t know 88 Refused
A job in which you or your coworkers use mercury	1 Yes 0 No 77 Don’t know 88 Refused

Now I’ll ask you about your health.

16. Have you ever had…?

16a. Yellow fever

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

When?

Less than 3 months ago	1 Yes 0 No 77 Don’t know 88 Refused
Between 3-6 months ago	1 Yes 0 No 77 Don’t know 88 Refused
7-12 months ago	1 Yes 0 No 77 Don’t know 88 Refused
13 months-5 years ago	1 Yes 0 No 77 Don’t know 88 Refused
More than 5 years ago	1 Yes 0 No 77 Don’t know 88 Refused

16b. Dengue

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

When?

Less than 3 months ago	1 Yes 0 No 77 Don’t know 88 Refused	Was it hemorrhagic? 1 Yes 0 No 77 Don’t know 88 Refused
Between 3-6 months ago	1 Yes 0 No 77 Don’t know 88 Refused	Was it hemorrhagic? 1 Yes 0 No 77 Don’t know 88 Refused
7-12 months ago	1 Yes 0 No 77 Don’t know 88 Refused	Was it hemorrhagic? 1 Yes 0 No 77 Don’t know 88 Refused
13 months-5 years ago	1 Yes 0 No 77 Don’t know 88 Refused	Was it hemorrhagic? 1 Yes 0 No 77 Don’t know 88 Refused
More than 5 years ago	1 Yes 0 No 77 Don’t know 88 Refused	Was it hemorrhagic? 1 Yes 0 No 77 Don’t know 88 Refused

16c. Chikungunya

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

When?

Less than 3 months ago	1 Yes 0 No 77 Don’t know 88 Refused
Between 3-6 months ago	1 Yes 0 No 77 Don’t know 88 Refused
7-12 months ago	1 Yes 0 No 77 Don’t know 88 Refused
13 months-5 years ago	1 Yes 0 No 77 Don’t know 88 Refused
More than 5 years ago	1 Yes 0 No 77 Don’t know 88 Refused

17. Have you ever been vaccinated for yellow fever?

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

18. 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. You do not have to answer any questions if they make you uncomfortable.

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

₀ None  End of questionnaire

₁ 1

₂ 2

₃ 3 or more

₇₇ Don’t know  End of questionnaire

₈₈ Refused  End of questionnaire

20. 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 (7 times or more per week)

₂ 2-6 times a week

₃ Once a week (4 times per month)

₄ 2-3 a month

₅ Once a month

₆ Less than once a month

₀ Never  Go to question #22

₇₇ Don’t know  Go to question #22

₈₈ Refused  Go to question #22

21. When you had vaginal 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

22. 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

23. 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

₄ No, we don’t use condoms

₀ I haven’t had regular sex with my partner

₇₇ Don’t know

₈₈ Refused

Thank you for answering this questionnaire. Do you have any questions?

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Appendix F5, version 19/MAY/2017

CDC estimates the average public reporting burden for this collection of information as 25 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).