TLC Baseline Assessment
Evaluation of TransLife Center (TLC): A Locally-Developed Combination Prevention Intervention for Transgender Women at High Risk of HIV Infection
Att 4c_TLC Baseline Assessment_23Aug2018
Baseline Assessment
OMB: 0920-1246
Form Approved
OMB No. 0920 – New
Expiration Date: XX/XX/XXXX
Evaluation of TransLife Center (TLC): A Locally-Developed Combination Prevention
Intervention for Transgender Women at High Risk of HIV Infection
Attachment 4c
TLC Baseline Assessment
Privacy Act Statement:
This information is collected under the authority of the Public Health Service Act, Section 301, "Research and Investigation," (42 U.S.C. 241); and Sections 304, 306 and 308(d) which discuss authority to maintain data and provide assurances of confidentiality for health research and related activities (42 U.S.C. 242 b, k, and m(d)). This information is also being collected in conjunction with the provisions of the Government Paperwork Elimination Act and the Paperwork Reduction Act (PRA). This information will only be used by the Centers for Disease Control and Prevention (CDC) staff to evaluate TransLife Center (TLC) as an HIV prevention intervention for transgender women.
Public reporting burden of this collection of information is estimated to average 60 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)
Study Trial Baseline Questionnaire
Document Version Date: 08/13/2018
Section 1: Demographic Characteristics
Section 2: Sexual Risk Questions
Section 3: PrEP Care Questions
Section 4: Gender Affirmation
Section 5: Collective Self-Esteem
Section 6: Social Support
Section 7: Substance Use
Section 8: Depressive Symptoms
Section 9: Anxiety Symptoms
Section 10: Victimization
Thank you for your participation in the TransLife Care evaluation. Please remember your responses to these questions are confidential and will be collected by an identification number and not by your name, so please be as honest as possible. We encourage you to answer every question. If you would like to skip a question, please inform the interviewer and they will advance to the next question.
We will begin by asking you about yourself and your background.
[Note to Interviewer: In self-administered mode, if a participant requests to skip an item, enter 98 to indicate “don’t know” and 99 to indicate “refuse”]
TLC – CDC Prevention
DEMOGRAPHIC QUESTIONNAIRE
(Interviewer-administered)
What is your date of birth? ____/____/______ [mm/dd/yyyy]
Which of the following best represents how you think of yourself?
1-Gay (lesbian or gay)
2 -Straight, this is not gay (or lesbian or gay)
3 –Bisexual
97 -Something else
98 – I don’t know the answer
What sex were you assigned at birth, on your original birth certificate?
1 – Male
2 – Female
98 – Don’t know
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
Do you currently describe yourself as male, female, or transgender?
Male
Female
Transgender
None of these
DEM5. Just to confirm, you were assigned [FILL from DEM3] at birth and now describe yourself as [FILL from DEM4]. Is that correct?
Yes
No
Refused
Don’t know
Are you Hispanic or Latino/a?
Yes
No
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
(If =1), Are you: Mexican, Mexican American, or Chicano/a; Puerto Rican; Cuban; or another category of Spanish/Hispanic/Latino/a that we have not mentioned?
1 - Yes, Mexican, Mexican American, Chicano/a
2 - Yes, Puerto Rican, Puerto Rican American
3 - Yes, Cuban, Cuban American
97 – Yes, Other Spanish/Hispanic/Latina
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
If =97, specify: ______________ [Interviewer: type in response verbatim]
What race or races do you consider yourself to be? (SELECT ONE OR MORE)
1 – White
2 – Black/African American
3 – Asian
4 – American Indian/Alaskan Native
5 – Native Hawaiian or Other Pacific Islander
99 – Refuse [Interviewer, do not read this response. ONLY select this option if the participant refuses to answer the question].
What is your highest level of education?
1 - Less than 8th grade
2 - 8th grade
3 - Some high school
4 – High school diploma or GED
5 - Trade School Certificate
6 - Some college
7 - Undergraduate degree
8 - Some graduate school
9 – Graduate degree
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
Are you currently a student?
1-Yes
0-No
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
Interviewer: The next set of questions is about your employment or work status.
Please indicate which of the following is true for you regarding your current work status:
1-Working for pay at a job or business
2-With a job or business, but currently not working (for example, on a leave of absence)
3-Looking for work [skip to DEM16]
4-Working, but not for pay (such as at a family business, internship or volunteering)
5-Not working and not looking for work [skip to DEM16]
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
What is your main occupation (job)? If you have more than one job, list the job in which you work the most hours: _________________________[Interviewer: type in response verbatim]
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
What was the approximate start date of this job: ___/___/_____ (dd/mm/yyyy)
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
How many hours per week do you work on average at this job? ______ hours/week
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
Do you have paid sick leave at this job? (That is, if you take a day off because you are sick, you still
receive pay)
1- Yes
0- No
98 –Don’t know [Interviewer: do not read. ONLY select this option if the participant indicates, “don’t know”].
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
Do you have another occupation (job)?
1- Yes
0- No [skip to DEM15]
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
What is your other occupation (job)? _______________________[Interviewer: type in response
verbatim]
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
Are you currently in need of help to find a job or in need of job counseling or training?
1-Yes
0-No
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
Did any program or agency help you get a job or provide job counseling or training in the past 4 months (not including commercial agencies, such as head-hunters or temp agencies)?
1 – Yes
0- No [skip to DEM18]
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
What is the name of the program and/or agency that provided this job-related service? _______________________[Interviewer: type in response verbatim]
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
What was your household income over the past 12-months from all sources before taxes? Household income refers to the total amount of money from all people living in the household.
1 - Less than $10,000
2 - $10,000 - $19,999
3 - $20,000 – $29,999
4 - $30,000 - $39,999
5 - $40,000 - $49,999
6 - $50,000 - $59,999
7 - $60,000 - $69,999
8 - $70,000 - $79,999
9 - $80,000 or more
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
Including yourself, how many people depend on this income? __________[Interviewer: type in numerical
response]
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
Do your sources of income or support include any of the following? Your sources of income may include public assistance and non-traditional jobs. Check all that apply:
1- Day labor (paid by the day with no promise of additional work)
2- Selling or dealing drugs
3- Sex work, survival sex or prostitution
4- Street income (panhandling, boosting or stealing)
5- Unemployment benefits
6- SSI or disability
7- Food stamps
8- Income provided by a partner
9- Income provided by other family members
10- Income provided by a “sugar daddy”
11- No income
12- Student stipend
13 None of the Above
Under-the-table (“off the books,” not reported to the government by the employer)
97- Something else
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
If =97, specify: ______________ [Interviewer: type in response verbatim]
Have you ever been arrested by the police?
1 – Yes
– No (skip to DEM22)
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
What was the approximate date when you were last arrested? __/__/____ (mm/dd/yyyy)
What were you charged with the LAST time you were arrested?
______________ [Interviewer: type in response verbatim]
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
Have you ever been in jail, prison, police lock-up, immigrant detention or juvenile detention?
1 – Yes
0 – No (skip to DEM23)
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
How many times have you been in jail, prison, police lock-up, immigrant detention or juvenile detention?
_______[Interviewer: type in numerical response]
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
What was the longest time you were in jail, prison, police lock-up, immigrant detention or juvenile detention? _________(in # years, #of months, # of days)
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
Have you been in jail, prison, police lock-up, immigrant detention or juvenile detention in the past 4 months?
1- Yes
0 – No
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
Are you currently in need of legal services or information (check all that apply) to do the following things: [Indicate Yes/No for each]
Change your name legally
Change how your gender is identified in government records as male or female (your gender marker)
Get help with criminal records (such as sealing, expungement, certificate of good conduct, healthcare wavier or executive clemency)?
Get help with a criminal case including a misdemeanor change, felony charge, or any city violation (like traffic violation)
Get help with transgender-related discrimination at work, school, housing or other public accommodation
Apply for government benefits, like a Link card, a medical card or other benefits?
Get help with an immigration issue or citizenship application?
97- Something else
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
If =97, specify: ______________ [Interviewer: type in response verbatim]
Did any program or agency provide you with legal services in the past 4 months?
1 – Yes
0- No [skip to DEM24]
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
What is the name of the program and/or agency that provided you with legal services? _______________________[Interviewer: type in response verbatim]
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
In your lifetime, have you ever been homeless at all? That is, you slept in a shelter for homeless people, on the streets, at a friend or relative’s house for a few nights or weeks, or another place not intended for sleeping.
1 – Yes
0 – No (skip to DEM26)
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
Approximately how many total nights have you not had a regular place to stay during your lifetime?
____years and _____ nights
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
In the past 4 months, were you homeless at any time?
1 – Yes
0 – No
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
What is your zip code where you currently live? ______ [Interviewer: type in 7-digit response]
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
How long have you lived at your current residence (in # of years and # of months)? _______
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
Which of the following best describes your current living situation? By current living situation we mean where you have been staying during the past seven days.
Your own place, a room, apartment, or house that is your home
Temporarily doubled up with others, in someone else’s house, apartment, or room
A temporary or transitional housing program
An SRO, that is a “single room occupancy” hotel or motel
In a shelter for homeless people
In jail, prison, or a halfway house
In drug treatment, a detox unit, or drug program housing
In a hospital, nursing home, or hospice
In an abandoned building, a public place like a bus station, a store or another place not intended for sleeping
On the street or anywhere outside such as a park, under a bridge, or in a campground
97- Something else
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
If =97, specify: ______________ [Interviewer: type in response verbatim]
Are you currently in need of housing services or information?
1 – Yes
0 – No
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
Did any program or agency help you with housing services in the past 4 months (not including commercial real estate agencies)?
1 – Yes
0 – No [skip to DEM31]
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
What is the name of the program that provided these housing services? ____________ [Interviewer: type
in response verbatim]
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
Do you currently live in group housing or public housing or get any rental assistance or help with paying for housing from a government program or an agency?
1 – Yes
0 – No
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
Are you currently involved in a committed relationship with someone who you consider your boyfriend/girlfriend, spouse, or domestic partner?
1 - Yes
2 - No (skip to END of DEM)
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
How long have you been in this relationship? (If you are currently involved in more than one relationship, select the most significant one).
1 - Less than a month
2 - One month to six months
3 - More than six months to a year
4 - More than a year to three years
5 - More than three years
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
ARBA
TW Version
This part of the survey will ask you about sex. Sex is a personal issue that can sometimes be sensitive or hard to talk about. This is especially true to those of us who are transgender because the bodies we have don’t always reflect who we are.
As transgender people, we do not all use the same words or names to talk about our body parts. This makes it hard for us to ask questions about sex that everyone who is participating in this study can relate to.
In this survey, we use the medical words that refer to your specific anatomy—words like penis, anus, and vagina. These are probably not the words you use. It is important for this research project that we use words that are clear so that everyone understands what question we are asking. We don’t want to disrespect you.
We will ask you about anal sex, vaginal sex, and oral sex.
Except where indicated, all questions about sex refer to sex you experienced because you wanted to, not because you were forced, coerced or otherwise made to have sex.
Remember your answers to these questions will be kept completely private. Please try your best to answer each question.
*************************ABOUT YOUR BODY*************************
Before we ask you about your sexual behaviors, please tell us a little about your body so we can ask you the right questions to assess your sexual health.
BODY1. Have you ever had gender affirming vaginal surgery (vaginoplasty)?
1 – Yes. I have had genital reconstruction. I have a vagina.
0 – No. I have not had vaginoplasty.
Is there an alternative word/slang term you prefer, rather than using medical terms, to describe your genitalia in questions about sexual behavior? If yes, please let us know now what word you prefer and we will use alternative language.
_____________________________
[NOTE TO PROGRAMMER: Note that for ARBA1, we need the participant’s response (see below placeholder, “1m”) coded so that it appears in subsequent questions that make reference to it. There are also other questions which make reference to previous responses, for example ARBA6 refers to the response to ARBA5, etc.]
The next set of questions will be about the LAST MONTH. Please think back to this date (<1m>) and enter something you did or something your family did during that time to help you remember the last month <____________>.
When answering the next questions, please think about the time when you did this (<ARBA1>), around this date (<1m>), until today.
**************************ANAL SEX***********************************
These next questions will be about anal sex. By “anal sex” we mean when a penis is put in someone else’s anus or butt.
Did you have anal sex in the LAST MONTH?
1 – Yes 0 – No (PROMPT for Interviewer)
How many partners have you had anal (insertive or receptive) sex with in the past month? This includes sex with or without a condom.
a. Total # anal sex partners in past month
__________
|
b. How many of these partners were HIV-positive? (They told you they were HIV positive)
__________
|
c. How many of these partners were HIV-negative? (They told you they were HIV negative)
__________
|
d. How many of these partners were of HIV unknown serostatus (They did not tell you their HIV status)?
__________
|
**Interviewer note: The sum of questions b, c, and d should equal question a.**
e. How many did you have anal sex with in exchange for things you needed (like money, drugs, food, shelter, etc.)?
__________
|
|
|
RECEPTIVE ANAL SEX
In the past month, how many times have you had receptive anal sex with these partners (that is, this person put his or her penis in your anus or butt)? This includes sex with or without a condom.
a. Total # times had receptive anal sex in past month
__________
If “0” skip to next question
|
b. Total # times had receptive anal sex in past month while under the influence of alcohol and/or drugs
__________
|
c. How many times have you had unprotected receptive anal sex? (this person put his or her penis in your anus or butt and no condom was used—or a condom was used but only for part of the time)
__________
If “0” skip to next question
|
g. How many times have you had unprotected receptive anal sex while under the influence of alcohol and/or drugs?(this person put his or her penis in your anus or butt and no condom was used—or a condom was used but only for part of the time)
_____________ |
INSERTIVE ANAL SEX
[Note to programmer – skip for those with Vaginoplasty]
In the past month, how many times have you had insertive anal sex with these partners (that is, you put your penis in his or her anus or butt)? This includes sex with or without a condom.
a. Total # times had insertive anal sex in past month
__________
If “0” skip to next question
|
b. Total # times had insertive anal sex in past month while under the influence of alcohol and/or drugs
__________
|
c. How many times have you had unprotected insertive anal sex? (you put your penis in his or her anus or butt and no condom was used—or a condom was used but only for part of the time)
__________
If “0” skip to next question
|
g. How many times have you had unprotected insertive anal sex while under the influence of alcohol and/or drugs?(you put your penis in his or her anus or butt and no condom was used—or a condom was used but only for part of the time)
_____________ |
********************************VAGINAL SEX**************************
These next questions will be about vaginal sex. By “vaginal sex” we mean when a penis is put into someone else’s vagina.
Remember your answers to these questions will be private. Please try your best to answer each question.
Except where indicated, all questions about sex refer to sex you experienced because you wanted to, not because you were forced, coerced or otherwise made to have sex.
Did you have vaginal sex in the LAST MONTH?
– Yes 0 – No (PROMPT for Interviewer)
How many partners have you had vaginal (insertive or receptive) sex with in the past month? This includes sex with or without a condom.
a. Total # vaginal sex partners in past month
__________
|
b. How many of these partners were HIV-positive? (They told you they were HIV positive)
__________
|
c. How many of these partners were HIV-negative? (They told you they were HIV negative)
__________
|
d. How many of these partners were of HIV unknown serostatus (They did not tell you their HIV status)?
__________
|
**Interviewer note: The sum of questions b, c, and d should equal question a.**
e. How many did you have vaginal sex with in exchange for things you needed (like money, drugs, food, shelter, etc.)?
__________
|
|
|
INSERTIVE VAGINAL SEX
[Note to programmer – skip for those with Vaginoplasty]
In the past month, how many times have you had insertive vaginal sex with these partners (that is, you put your penis in a partner’s vagina)? This includes sex with or without a condom.
a. Total # times had insertive vaginal sex in past month
__________
If “0” skip to next question
|
b. Total # times had insertive vaginal sex in past month while under the influence of alcohol and/or drugs
__________
|
c. How many times have you had unprotected insertive vaginal sex? (you put your penis in a partner’s vagina and no condom was used—or a condom was used but only for part of the time)
__________
If “0” skip to next question
|
g. How many times have you had unprotected insertive vaginal sex while under the influence of alcohol and/or drugs? (you put your penis in a partner’s vagina and no condom was used—or a condom was used but only for part of the time)
_____________ |
RECEPTIVE VAGINAL SEX
[Note to programmer – skip for those with a Penis]
In the past month, how many times have you had receptive vaginal sex with these partners (that is, this person put his or her penis in your vagina)? This includes sex with or without a condom.
a. Total # times had receptive vaginal sex in past month
__________
If “0” skip to next question
|
b. Total # times had receptive vaginal sex in past month while under the influence of alcohol and/or drugs
__________
|
c. How many times have you had unprotected receptive vaginal sex? (this person put his or her penis in your vagina and no condom was used—or a condom was used but only for part of the time)
__________
If “0” skip to next question
|
g. How many times have you had unprotected receptive vaginal sex while under the influence of alcohol and/or drugs?(this person put his or her penis in your vagina and no condom was used—or a condom was used but only for part of the time)
_____________ |
*****************************PARTNER HISTORY************************
[NOTE TO PROGRAMMER: Note that for ARBA14, we need the participant’s response (see below placeholder, “4m”) coded so that it appears in subsequent questions that make reference to it.
The next set of questions will be about the LAST 4 months. Please think back to this date (<4m>) and enter something you did or something your family did during this time to help you remember the last month <____________>.
When answering the next questions, please think about the time when you did this (ARBA13>), around this date (<4m>), until today.
Thinking about the LAST 4 MONTHS (from <4m> until <today>), please enter the initials of your LAST sexual partner (someone you’ve had anal or vaginal sex with). <_ARBA14>
Thinking about the LAST 4 MONTHS (from <4m> until <today>), did you have another partner in addition to <ARBA14> (someone you’ve had anal or vaginal sex with)?
1 – Yes 0 – No (skip to ARBA17)
Please enter the initials of this sexual partner <ARBA15>
Thinking about the LAST 4 MONTHS (from <4m> until <today>), did you have another partner in addition to <ARBA14, ARBA15> (someone you’ve had anal or vaginal sex with)?
1 – Yes 0 – No (skip to ARBA17)
Please enter the initials of this sexual partner <ARBA16>
We’re going to begin by asking you about your LAST partner <ARBA14>.
What was the HIV status of this partner (<ARBA14>)?
He or she was HIV positive.
He or she was HIV negative.
I don’t know his/her HIV status. (skip to ARBA18)
How did you find out about this partner’s HIV status?
1 He or she told me
2 I found out through another person
3 I assumed his/her HIV status
Other
Other, Please Specify.
How would you describe your relationship with this partner (<ARBA14>)?
1. Serious relationship (boyfriend/girlfriend), someone you dated for a while and feel very close to.
2 Casually dating but not serious
3 Sleeping with this person (fuck buddy or booty call) but not dating
4 One night stand
5 Stranger or anonymous person
Was this partner <ARBA14> a paying (they paid you money for sex) or trade (you traded food, drugs, shelter or something else for sex) partner?
1 – Yes 0 – No
How long have you been with <ARBA14>?
Less than a month
1 to 3 months
4 to 6 months
7 months to 11 months
1 to 3 years
Over 3 years
How frequently did you drink alcohol before having anal or vaginal sex with this partner (<ARBA14>)?
1=Never
2=Less than half the time
3=About half the time
4=More than half the time
5=Always
How frequently did you use drugs before having anal or vaginal sex with this partner (<ARBA14>)?
1=Never
2=Less than half the time
3=About half the time
4=More than half the time
5=Always
What was this partner’s (<ARBA14>) gender?
1 – Male
2 – Female
3 – Transgender (male-to-female)
4 – Transgender (female-to-male)
[Note to Programmer: Skip to ARBA29 for those with Vaginoplasty]
In the LAST 4 MONTHS, how many times did you have anal sex with this partner (<ARBA14>) with you as the top (you put your penis in his or her anus or butt)? [skip to ARBA29 if 0]
You said you had anal sex with this partner (<ARBA14>) with you as the top this many times during the LAST 4 MONTHS (<ARBA28>). Thinking about those times, how many times did you use a condom during anal sex with this partner (<ARBA14>)?
In the last 4 months, how many times did you have anal sex with this partner (<ARBA14>) with you as the bottom (the partner put their penis in your anus or butt)? [skip to ARBA30 if 0]
You said you had anal sex with this partner (<ARBA14>) with you as the bottom this many times during the LAST 4 MONTHS (<ARBA29>). Thinking about those times, how many times did you use a condom during anal sex with this partner (<ARBA14>)?
[Note to Programmer: Skip to ARBA31 for those with Vaginoplasty]
In the LAST 4 MONTHS, how many times did you have vaginal sex with this partner (<ARBA14>) with you as the top (you put your penis in his or her vagina)? [skip to ARBA31 if 0]
You said you had vaginal sex with this partner (<ARBA14>) with you as the top this many times during the LAST 4 MONTHS (<ARBA30>). Thinking about those times, how many times did you use a condom during anal sex with this partner (<ARBA14>)?
[Note to Programmer: Skip to ARBA32 for those with a Penis]
In the last 4 months, how many times did you have vaginal sex with this partner (<ARBA14>) with you as the bottom (the partner put their penis in your vagina)? [skip to ARBA32 if 0]
You said you had vaginal sex with this partner (<ARBA14>) with you as the bottom this many times during the LAST 4 MONTHS (<ARBA31>). Thinking about those times, how many times did you use a condom during anal sex with this partner (<ARBA14>)?
************************* SECOND PARTNER****************************
Now we’re going to ask you about, this partner <ARBA15>
What was the HIV status of this partner (<ARBA15>)?
He or she was HIV positive.
He or she was HIV negative.
98 I don’t know his/her HIV status. (skip to ARBA33)
How did you find out about this partner’s HIV status?
1 He or she told me
2 I found out through another person
3 I assumed his/her HIV status
97 Other
Other. Please Specify.
How would you describe your relationship with this partner (<ARBA15>)?
1. Serious relationship (boyfriend/girlfriend), someone you dated for a while and feel very close to.
2 Casually dating but not serious
3 Sleeping with this person (fuck buddy or booty call) but not dating
4 One night stand
5 Stranger or anonymous person
Was this partner <ARBA15> a paying (they paid you money for sex) or trade (you traded food, drugs, shelter or something else for sex) partner?
1 – Yes 0 – No
How long have you been with <ARBA15>?
Less than a month
1 to 3 months
4 to 6 months
7 months to 11 months
1 to 3 years
Over 3 years
How frequently did you drink alcohol before having anal or vaginal sex with this partner (<ARBA15>)?
1=Never
2=Less than half the time
3=About half the time
4=More than half the time
5=Always
How frequently did you use drugs before having anal or vaginal sex with this partner (<ARBA15>)?
1=Never
2=Less than half the time
3=About half the time
4=More than half the time
5=Always
What was this partner’s (<ARBA15>) gender?
1 – Male
2 – Female
3 – Transgender (male-to-female)
4 – Transgender (female-to-male)
[Note to Programmer: Skip for those with Vaginoplasty]
In the LAST 4 MONTHS, how many times did you have anal sex with this partner (<ARBA15>) with you as the top (you put your penis in his or her anus or butt)? [skip to ARBA48 if 0]
You said you had anal sex with this partner (<ARBA15>) with you as the top this many times during the LAST 4 MONTHS (<ARBA47>). Thinking about those times, how many times did you use a condom during anal sex with this partner (<ARBA15>)?
In the LAST 4 MONTHS, how many times did you have anal sex with this partner (<ARBA15>) with you as the bottom (the partner put their penis in your anus or butt)? [skip to ARBA49 if 0]
You said you had anal sex with this partner (<ARBA15>) with you as the bottom this many times during the LAST 4 MONTHS (<ARBA48>). Thinking about those times, how many times did you use a condom during anal sex with this partner (<ARBA15>)?
[Note to Programmer: Skip to ARBA31 for those with Vaginoplasty]
In the LAST 4 MONTHS, how many times did you have vaginal sex with this partner (<ARBA15>) with you as the top (you put your penis in his or her vagina)? [skip to ARBA50 if 0]
You said you had vaginal sex with this partner (<ARBA15>) with you as the top this many times during the LAST 4 MONTHS (<ARBA49>). Thinking about those times, how many times did you use a condom during vaginal sex with this partner (<ARBA15>)?
[Note to Programmer: Skip to ARBA32 for those with a Penis]
In the LAST 4 MONTHS, how many times did you have vaginal sex with this partner (<ARBA15>) with you as the bottom (the partner put their penis in your vagina)? [skip to ARBA51 if 0]
You said you had vaginal sex with this partner (<ARBA15>) with you as the bottom this many times during the LAST 4 MONTHS (<ARBA50>). Thinking about those times, how many times did you use a condom during vaginal sex with this partner (<ARBA15>)?
***************************THIRD PARTNER*****************************
Now we’re going to ask you about this partner, <ARBA16>
What was the HIV status of this partner (<ARBA15>)?
He or she was HIV positive.
He or she was HIV negative.
98 I don’t know his/her HIV status. (skip to ARBA56)
How did you find out about this partner’s HIV status?
1 He or she told me
2 I found out through another person
3 I assumed his/her HIV status
97 Other
Other. Please Specify.
How would you describe your relationship with this partner (<ARBA16>)?
1. Serious relationship (boyfriend/girlfriend), someone you dated for a while and feel very close to.
2 Casually dating but not serious
3 Sleeping with this person (fuck buddy or booty call) but not dating
4 One night stand
5 Stranger or anonymous person
Was this partner <ARBA16> a paying (they paid you money for sex) or trade (you traded food, drugs, shelter or something else for sex) partner?
1 – Yes 0 – No
How long have you been with <ARBA16>?
Less than a month
1 to 3 months
4 to 6 months
7 months to 11 months
1 to 3 years
Over 3 years
How frequently did you drink alcohol before having anal or vaginal sex with this partner (<ARBA16>)?
1=Never
2=Less than half the time
3=About half the time
4=More than half the time
5=Always
How frequently did you use drugs before having anal or vaginal sex with this partner (<ARBA16>)?
1=Never
2=Less than half the time
3=About half the time
4=More than half the time
5=Always
What was this partner’s (<ARBA15>) gender?
1 – Male
2 – Female
3 – Transgender (male-to-female)
4 – Transgender (female-to-male)
[Note to Programmer: Skip to ARBA32 for those with Vaginoplasty]
In the LAST 4 MONTHS, how many times did you have anal sex with this partner (<ARBA15>) with you as the top (you put your penis in his or her anus or butt)? [skip to ARBA64 if 0]
You said you had anal sex with this partner (<ARBA15>) with you as the top this many times during the LAST 4 MONTHS (<ARBA66>). Thinking about those times, how many times did you use a condom during anal sex with this partner (<ARBA15>)?
How many times did you have anal sex with this partner (<ARBA15>) during the LAST 4 MONTHS with you as the bottom (this partner put their penis in your anus or butt)? [skip to ARBA68 if 0]
You said you had anal sex with this partner (<ARBA15>) with you as the bottom this many times during the LAST 4 MONTHS (<ARBA67>). Thinking about those times, how many times did you use a condom during anal sex with this partner (<ARBA15>)?
[Note to Programmer: Skip to ARBA32 for those with vaginoplasty]
In the LAST 4 MONTHS, how many times did you have vaginal sex with this partner (<ARBA15>) with you as the top (you put your penis in his or her vagina)? [skip to ARBA69 if 0]
You said you had vaginal sex with this partner (<ARBA15>) with you as the top this many times during the LAST 4 MONTHS (<ARBA65>). Thinking about those times, how many times did you use a condom during vaginal sex with this partner (<ARBA15>)?
[Note to Programmer: Skip to ARBA32 for those with a Penis]
How many times did you have vaginal sex with this partner (<ARBA15>) during the LAST 4 MONTHS with you as the bottom (this partner put their penis in your vagina)? [skip to ARBA70 if 0]
You said you had vaginal sex with this partner (<ARBA15>) with you as the bottom this many times during the LAST 4 MONTHS (<ARBA69>). Thinking about those times, how many times did you use a condom during vaginal sex with this partner (<ARBA15>)?
************************ADDITIONAL PARNTERS************************
Thinking about the LAST 4 MONTHS, how many other people have you had vaginal or anal sex with besides these partners (<ARBA14>, <ARBA15>, <ARBA16>)? Remember to answer about the LAST 4 MONTHS (from <4m> until <today>). ________ (If “0” partners, skip to END OF ARBA)
Think of the other sexual partners you’ve had (<ARBA74> partners) in the LAST 4 MONTHS. How many times did you have anal or vaginal sex with any of these partners during the LAST 4 MONTHS? _______
You said you had anal or vaginal sex with other partners besides these 3 partners (<ARBA14>, <ARBA15>, <ARBA16>) this many times during the LAST 4 MONTHS (<ARBA72>). Thinking about those times, how many times did you have sex without using a condom during anal or vaginal sex with these other partners? _________
PREP QUESTIONS (PRP)
(Interviewer-administered)
One way to prevent HIV infection is called PrEP, which stands for pre-exposure prophylaxis. PrEP is a way of preventing HIV infection by giving HIV-negative people HIV medicines. The following questions are about your thoughts and opinions of this way of preventing HIV infection.
Have you heard of HIV-negative people taking HIV medication before sex because they thought it would lower their chances of getting HIV (also known as PrEP)?
1-Yes
0-No
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
How effective do you think taking an HIV medication every day will be in preventing HIV for people who have sex without using condoms?
Not effective at all
Slightly effective
Moderately effective
Very effective
Extremely effective
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
How interested are you in taking PrEP medication to help prevent HIV infection?
1-very interested
2-somewhat interested
3-somewhat uninterested
4-very uninterested
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
Have you ever taken HIV medication before sex because you thought it would lower your chances of getting HIV (also known as PrEP)?
1-Yes
0-No (SKIP to PRP11)
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
When taking PrEP, how often did you use condoms during anal or vaginal sex?
1-Never
2-Less than half the time
3-About half the time
4-More than half the time
5-always
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
Have you taken PrEP in the last 4 months?
1-Yes
0-No (SKIP to PRP11)
Have you taken PrEP in the past month?
1-Yes
0-No
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
In the calendar [SHOW CARD], please indicate whether or not you have taken PrEP on each day during the past month, beginning with yesterday.
[Note to programmer: Program calendar input to begin with the day before the current visit through 4 prior weeks with Y/N radio button or checkbox for each day – if possible, display on one page for ease of data entry by interviewer.]
[HANDCARD – sample calendar below
YEAR |
SUN |
MON |
TUES |
WED |
THURS |
FRI |
SAT |
|
|
|
|
|
|
1-fill in dates
|
2
|
MONTH |
3
|
4
|
5
|
6
|
7
|
8
|
9
|
|
10
|
11
|
12
|
13
|
14
|
15
|
16
|
|
17
|
18
|
19
|
20
|
21
|
22
|
23
|
|
24
|
25
|
26
|
27
|
28
|
29
|
30
|
[NOTE TO PROGRAMMER: Program Flag to note if participant has used PrEP at least 4 times/week for every sequential week. The flag at the end of the assessment should indicate that a hair sample and release of information for PrEP care engagement should be collected.]
In the past 4 months, how many times have you seen a provider for PrEP care and follow-up? ________________ [Interviewer: type in numerical response]
In the past 12 months, how many times have you seen a provider for PrEP care and follow-up? ________________ [Interviewer: type in numerical response]
Do you have a person you think of as your personal doctor or health care provider?
1 - Yes, only one
2 - Yes, More than one
- No
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
Where do you most often receive health care services?
1 - County clinic
2 - Community-based clinic (non-county department)
3 - Private doctor's office
4 - HMO (health maintenance organization)
5 - School or college clinic
6 - Emergency room
7 - Mobile Health Team
8 - Don't have regular source of health care
9 - Don't seek health care
97 -Something else
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
PRP12a. If =97, specify ____________ [Interviewer: type in response verbatim]
What kind of insurance do you currently use to pay for health care (check all that apply)?
1 Medicaid (including CountyCare) or Medicare
2 Veteran's Administration
3 Private or work insurance (e.g. Blue Cross)
4 School-based insurance
5 COBRA
6 No insurance
97 -Something else
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
PRP13a. If =97, specify ____________ [Interviewer: type in response verbatim]
Have you EVER been told by a doctor or nurse that you had a Sexually Transmitted Infection other than HIV?
– Yes
0
– No (skip to END
of PRP)
99
– Refuse [Interviewer: do not read. ONLY select this option if
the participant refuses to answer the question].
With which sexually transmitted infection(s) were you diagnosed (check all that apply)?
1 – Anal warts (HPV)
2 – Chlamydia
3 – Genital warts (HPV)
4 – Gonorrhea
5 – Genital herpes
– Syphilis
97 – Other
PRP15a. If =97, specify ____________ [Interviewer: type in response verbatim]
GENDER AFFIRMATION
(Interviewer-Administered)
The following questions will ask you about experiences you may have had. For questions that ask about age when these experiences occurred, please use round numbers and round to the highest number. For example, if your answer is 15 and a half years old, please enter 16.
Have you ever taken female hormones?
1 – Yes
– No (skip to GND2)
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
GND1a. At what age did you begin taking hormones?
___ ____ [Interviewer: Enter age in two-digit numerical value]
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
GND1b. How many times in the last 4 months have you taken hormones?
___ ____ [Interviewer: Enter age in two-digit numerical value]
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
GND2. In the last 4 months, where did you usually get your hormones? (Check all that apply)
1- From a clinic or health center
2- From a private doctor, private practice or HMO
3- On the street (dealer or doctor practicing illegally/black market)
4- From a lover or sex partner
5- From a friend
97 – Something else
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
GND2a. If =97, specify ____________ [Interviewer: type in response verbatim]
GND3. Have you ever injected silicone?
1 – Yes
0– No (SKIP to GND4)
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
GND3a. Where have you injected silicone? (Check all that apply)
1 – In your cheeks, chin or face
2 – In your hips or buttocks
3 – In your breasts
97 – Somewhere else
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
GND3a. If =97, specify ____________ [Interviewer: type in response verbatim]
GND4. Have you ever had any of the following types of gender confirming surgery/laser therapy? Remember, your answers are completely confidential (Check all that apply).
1 – None – never had any surgery/laser therapy
2 – Breast implants (breast augmentation)
3 – Facial or neck surgery (for example, nose job, cheek implants, forehead lift, etc.)
4 – Vaginal surgery (vaginoplasty)
97 – Somewhere else
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
GND4a. If =97, specify ____________ [Interviewer: type in response verbatim]
The following questions are about your attitudes towards your gender identity.
GND5. How important is it to you to have a driver’s license or ID that says you are female?
Not at all important
Slightly important
Moderately important
Very important
Extremely important
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
GND6. How important is it to you that strangers call you “she” when talking about you?
Not at all important
Slightly important
Moderately important
Very important
Extremely important
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
GND7. How important is it to you that family members call you “she” when talking about you?
Not at all important
Slightly important
Moderately important
Very important
Extremely important
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
GND8. How important is it to you that your friends call you “she” when talking about you?
Not at all important
Slightly important
Moderately important
Very important
Extremely important
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
GND9. How important is it to you that health care providers call you “she” when talking about you?
Not at all important
Slightly important
Moderately important
Very important
Extremely important
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
GND10. How comfortable are you with going out in public during the day?
Not at all comfortable
Slightly comfortable
Moderately comfortable
Very comfortable
Extremely comfortable
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
GND11. How comfortable are you with people knowing that you are transgender?
Not at all comfortable
Slightly comfortable
Moderately comfortable
Very comfortable
Extremely comfortable
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
GND12. How satisfied are you with your body the way it is right now? By “right now”, I mean in general, not just today.
Not at all satisfied
Slightly satisfied
Moderately satisfied
Very satisfied
Extremely satisfied
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
GND13. How satisfied are you with the way you look right now? By “right now”, I mean in general, not just today.
Not at all satisfied
Slightly satisfied
Moderately satisfied
Very satisfied
Extremely satisfied
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
GND14. How satisfied are you with your current level of femininity?
Not at all satisfied
Slightly satisfied
Moderately satisfied
Very satisfied
Extremely satisfied
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
Collective Self-Esteem Scale (CSES)
We are all members of different communities. Some of these communities reflect gender, race, religion, nationality, ethnicity, and socioeconomic class. We would like you to consider your membership within a larger community of people who identify as transgender and respond to the following statements on the basis of how you feel about this group and your memberships in it. There are no right or wrong answers to any of these statements; we are interested in your honest reactions and opinions.
Please read each statement carefully and respond by using the following scale where:
1= strongly disagree, 2= disagree, 3=disagree somewhat, 4= neutral, 5=agree somewhat, 6=agree, 7= strongly agree.
I am a worthy member of the transgender community that I belong to.
1 2 3 4 5 6
Strongly Disagree Disagree Agree Agree Strongly
Disagree somewhat somewhat agree
I often regret that I belong to the transgender community. *
1 2 3 4 5 6 7
Strongly Disagree Disagree Neutral Agree Agree Strongly
Disagree somewhat somewhat agree
Overall, the transgender community is considered good by others.
1 2 3 4 5 6 7
Strongly Disagree Disagree Neutral Agree Agree Strongly
Disagree somewhat somewhat agree
Overall, my membership in the transgender community has very little to do with how I feel about myself.*
1 2 3 4 5 6 7
Strongly Disagree Disagree Neutral Agree Agree Strongly
Disagree somewhat somewhat agree
I feel I don’t have much to offer to the transgender community that I belong to. *
1 2 3 4 5 6 7
Strongly Disagree Disagree Neutral Agree Agree Strongly
Disagree somewhat somewhat agree
In general, I’m glad to be a member of the transgender community that I belong to.
1 2 3 4 5 6 7
Strongly Disagree Disagree Neutral Agree Agree Strongly
Disagree somewhat somewhat agree
Most people consider the transgender community, on the average, to be more ineffective than other communities or social groups. *
1 2 3 4 5 6 7
Strongly Disagree Disagree Neutral Agree Agree Strongly
Disagree somewhat somewhat agree
The transgender community that I belong to is an important reflection of who I am.
1 2 3 4 5 6 7
Strongly Disagree Disagree Neutral Agree Agree Strongly
Disagree somewhat somewhat agree
I am a cooperative participant in the transgender community that I belong to.
1 2 3 4 5 6 7
Strongly Disagree Disagree Neutral Agree Agree Strongly
Disagree somewhat somewhat agree
Overall, I often feel that the transgender community of which I am a member is not worthwhile. *
1 2 3 4 5 6 7
Strongly Disagree Disagree Neutral Agree Agree Strongly
Disagree somewhat somewhat agree
In general, others respect the transgender community that I am a member of.
1 2 3 4 5 6 7
Strongly Disagree Disagree Neutral Agree Agree Strongly
Disagree somewhat somewhat agree
The transgender community that I belong to is unimportant to my sense of what kind of a person I am. *
1 2 3 4 5 6 7
Strongly Disagree Disagree Neutral Agree Agree Strongly
Disagree somewhat somewhat agree
I often feel I’m a useless member of the transgender community. *
1 2 3 4 5 6 7
Strongly Disagree Disagree Neutral Agree Agree Strongly
Disagree somewhat somewhat agree
I feel good about the transgender community that I belong to.
1 2 3 4 5 6 7
Strongly Disagree Disagree Neutral Agree Agree Strongly
Disagree somewhat somewhat agree
In general, others think that the transgender community that I am a member of is unworthy.*
1 2 3 4 5 6 7
Strongly Disagree Disagree Neutral Agree Agree Strongly
Disagree somewhat somewhat agree
In general, belonging to the transgender community is an important part of my self-image.
1 2 3 4 5 6 7
Strongly Disagree Disagree Neutral Agree Agree Strongly
Disagree somewhat somewhat agree
*= item reverse scored
SOCIAL SUPPORT
(Interviewer-Administered)
The next set of questions are about support you may receive from others.
Thinking about the last 4 months, how often have you had someone available…
To help take care of you if you are sick? Would you say…
1=none of the time
2=a little of the time
3=some of the time
4=most of the time
5=all of the time
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
To help with daily chores if you are sick? Would you say… (Tangible support)
1=none of the time
2=a little of the time
3=some of the time
4=most of the time
5=all of the time
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
To get together with you for relaxation? Would you say…( Positive social interaction)
1=none of the time
2=a little of the time
3=some of the time
4=most of the time
5=all of the time
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
To understand your problems? Would you say…( Emotional/informational support)
1=none of the time
2=a little of the time
3=some of the time
4=most of the time
5=all of the time
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
To love you and make you feel wanted? Would you say… (Affectionate support)
1=none of the time
2=a little of the time
3=some of the time
4=most of the time
5=all of the time
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
To borrow money from when you need it? Would you say…
1=none of the time
2=a little of the time
3=some of the time
4=most of the time
5=all of the time
99-Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
THE ALCOHOL, SMOKING, AND SUBSTANCE INVOLVEMENT SCREENING TEST (ASSIST)
INSTRUCTIONS: Thank you for agreeing to take part in this brief interview about alcohol, tobacco products and other drugs. I am going to ask you some questions about your experience of using these substances across your lifetime and in the past three months. These substances can be smoked, swallowed, snorted, inhaled, injected or taken in the form of pills.
Some of the substances listed may be prescribed by a health care provider (like amphetamines, sedatives, pain medications). For this interview, we will not record medications that are used as prescribed by your health care provider. However, if you have taken such medications for reasons other than prescription, or taken them more frequently or at higher doses than prescribed, please let me know. While we are also interested in knowing about your use of various illicit drugs, please be assured that information on such use will be treated as strictly confidential.
Question 1 |
||
In your life, which of the following substances have you ever used? (NON-MEDICAL USE ONLY)“not prescribed by your health care provider” |
No |
Yes |
1. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) |
0 |
3 |
2. Alcoholic beverages (beer, wine, spirits, etc.) |
0 |
3 |
3. Cannabis (marijuana, pot, grass, hash, etc.) |
0 |
3 |
4. Cocaine (coke, crack, etc.) |
0 |
3 |
5. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) |
0 |
3 |
6. Inhalants (nitrous, glue, petrol, paint thinner, etc.) |
0 |
3 |
7. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) |
0 |
3 |
8. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) |
0 |
3 |
9. Opioids (heroin, morphine, methadone, codeine, etc.) |
0 |
3 |
10. Other – specify: |
0 |
3 |
If all questions in Section 1 (1 – 10) were NO, skip to Section 8 (#61). Otherwise, skip to Section 2 for those substances answered YES.
Question 2 |
|||||
In the past three months, how often have you used the substances you mentioned? (Only answer for those marked yes above) |
Never |
Once or Twice |
Monthly |
Weekly |
Daily or Almost Daily |
1. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)? |
0 |
2 |
3 |
4 |
6 |
2. Alcoholic beverages (beer, wine, spirits, etc.)? |
0 |
2 |
3 |
4 |
6 |
3. Cannabis (marijuana, pot, grass, hash, etc.)? |
0 |
2 |
3 |
4 |
6 |
4. Cocaine (coke, crack, etc.)? |
0 |
2 |
3 |
4 |
6 |
5. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)? |
0 |
2 |
3 |
4 |
6 |
6. Inhalants (nitrous, glue, petrol, paint thinner, etc.)? |
0 |
2 |
3 |
4 |
6 |
7. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)? |
0 |
2 |
3 |
4 |
6 |
8. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)? |
0 |
2 |
3 |
4 |
6 |
9. Opioids (heroin, morphine, methadone, codeine, etc.)? |
0 |
2 |
3 |
4 |
6 |
10. Other - specify: (ACASI will copy from section 1) |
0 |
2 |
3 |
4 |
6 |
If all items in Section 2 were answered “Never”, skip to Section 6.
If any substances in Section 2 = 3, 4, 5, or 6, continue with Sections 3-5 for each substance used in the past 3 months
Question 3 |
|||||
During the past three months, how often have you had a strong desire or urge to use (if used in the past 3 months in section 2) |
Never |
Once or Twice |
Monthly |
Weekly |
Daily or Almost Daily |
1. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)? |
0 |
3 |
4 |
5 |
6 |
2. Alcoholic beverages (beer, wine, spirits, etc.)? |
0 |
3 |
4 |
5 |
6 |
3. Cannabis (marijuana, pot, grass, hash, etc.? |
0 |
3 |
4 |
5 |
6 |
4. Cocaine (coke, crack, etc.)? |
0 |
3 |
4 |
5 |
6 |
5. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)? |
0 |
3 |
4 |
5 |
6 |
6. Inhalants (nitrous, glue, petrol, paint thinner, etc.)? |
0 |
3 |
4 |
5 |
6 |
7. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)? |
0 |
3 |
4 |
5 |
6 |
8. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)? |
0 |
3 |
4 |
5 |
6 |
9. Opioids (heroin, morphine, methadone, codeine, etc.)? |
0 |
3 |
4 |
5 |
6 |
10. Other specify: ? (ACASI will copy from section 1) |
0 |
3 |
4 |
5 |
6 |
Question 4 |
|||||
During the past three months, how often has your use of (FIRST DRUG, SECOND DRUG, etc. ACASI will pull from section 1) led to health, social, legal or financial problems? |
Never |
Once or Twice |
Monthly |
Weekly |
Daily or Almost Daily |
1. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)? |
0 |
4 |
5 |
6 |
7 |
2. Alcoholic beverages (beer, wine, spirits, etc.)? |
0 |
4 |
5 |
6 |
7 |
3. Cannabis (marijuana, pot, grass, hash, etc.)? |
0 |
4 |
5 |
6 |
7 |
4. Cocaine (coke, crack, etc.)? |
0 |
4 |
5 |
6 |
7 |
5. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)? |
0 |
4 |
5 |
6 |
7 |
6. Inhalants (nitrous, glue, petrol, paint thinner, etc.)? |
0 |
4 |
5 |
6 |
7 |
7. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)? |
0 |
4 |
5 |
6 |
7 |
8. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)? |
0 |
4 |
5 |
6 |
7 |
9. Opioids (heroin, morphine, methadone, codeine, etc.)? |
0 |
4 |
5 |
6 |
7 |
10. Other - specify: _? (ACASI will specify from section 1) |
0 |
4 |
5 |
6 |
7 |
-
Question 5
During the past three months, how often have you failed to do what was normally expected of you because of your use of (FIRST DRUG, SECOND DRUG, etc. ACASI will pull from section 1)
Never
Once or Twice
Monthly
Weekly
Daily or
Almost Daily
1. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)?
0
5
6
7
8
2. Alcoholic beverages (beer, wine, spirits, etc.)?
0
5
6
7
8
3. Cannabis (marijuana, pot, grass, hash, etc.)?
0
5
6
7
8
4. Cocaine (coke, crack, etc.)?
0
5
6
7
8
5. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)?
0
5
6
7
8
6. Inhalants (nitrous, glue, petrol, paint thinner, etc.)?
0
5
6
7
8
7. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)?
0
5
6
7
8
8. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)?
0
5
6
7
8
9. Opioids (heroin, morphine, methadone, codeine, etc.)?
0
5
6
7
8
10. Other –specify ? (ACASI will copy from section 1)
0
5
6
7
8
Question 6 |
|||
Has a friend or relative or anyone else ever expressed concern about your use of (FIRST DRUG, SECOND DRUG, etc. ACASI will pull from section 1) |
No, Never |
Yes, in the past 3 months |
Yes, but not in the past 3 months |
1. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)? |
0 |
6 |
3 |
2. Alcoholic beverages (beer, wine, spirits, etc.)? |
0 |
6 |
3 |
3. Cannabis (marijuana, pot, grass, hash, etc.)? |
0 |
6 |
3 |
4. Cocaine (coke, crack, etc.)? |
0 |
6 |
3 |
5. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)? |
0 |
6 |
3 |
6. Inhalants (nitrous, glue, petrol, paint thinner, etc.)? |
0 |
6 |
3 |
7. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)? |
0 |
6 |
3 |
8. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)? |
0 |
6 |
3 |
9. Opioids (heroin, morphine, methadone, codeine, etc.)? |
0 |
6 |
3 |
10. Other – specify ? (ACASI will copy from section 1) |
0 |
6 |
3 |
Question 7 |
|||
Have you ever tried and failed to control, cut down or stop using (FIRST DRUG, SECOND DRUG, etc. ACASI will pull from section 1) |
No, Never |
Yes, in the past 3 months |
Yes, but not in the last 3 months |
1. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)? |
0 |
6 |
3 |
2. Alcoholic beverages (beer, wine, spirits, etc.)? |
0 |
6 |
3 |
3. Cannabis (marijuana, pot, grass, hash, etc.)? |
0 |
6 |
3 |
4. Cocaine (coke, crack, etc.)? |
0 |
6 |
3 |
5. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)? |
0 |
6 |
3 |
6. Inhalants (nitrous, glue, petrol, paint thinner, etc.)? |
0 |
6 |
3 |
7. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)? |
0 |
6 |
3 |
8. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)? |
0 |
6 |
3 |
9. Opioids (heroin, morphine, methadone, codeine, etc.)? |
0 |
6 |
3 |
10. Other – specify _? (ACASI copies from section 1 |
0 |
6 |
3 |
Question 8 |
|||
|
No, Never |
Yes, in the past 3 months |
Yes, but not in the past 3 months |
1. Have you ever used any drug by injection? (NON-MEDICAL USE ONLY - Not prescribed your health care provider) |
0 |
2 |
1 |
Short Depression Scale (CES‐D 10)
(Interviewer-Administered)
Below is a list of some of the ways you may have felt or behaved. Please indicate how often you
have felt this way during the past week by checking the appropriate box for each question.
I was bothered by things that usually don't bother me.
1-Rarely or none of the time (less than 1 day)
2-Some or a little of the time (1‐2 days)
3-Occasionally or a moderate amount of time (3‐4 days)
4-All of the time (5‐7 days)
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
I had trouble keeping my mind on what I was doing
1-Rarely or none of the time (less than 1 day)
2-Some or a little of the time (1‐2 days)
3-Occasionally or a moderate amount of time (3‐4 days)
4-All of the time (5‐7 days)
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
I felt depressed.
1-Rarely or none of the time (less than 1 day)
2-Some or a little of the time (1‐2 days)
3-Occasionally or a moderate amount of time (3‐4 days)
4-All of the time (5‐7 days)
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
I felt that everything I did was an effort.
1-Rarely or none of the time (less than 1 day)
2-Some or a little of the time (1‐2 days)
3-Occasionally or a moderate amount of time (3‐4 days)
4-All of the time (5‐7 days)
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
I felt hopeful about the future.
1-Rarely or none of the time (less than 1 day)
2-Some or a little of the time (1‐2 days)
3-Occasionally or a moderate amount of time (3‐4 days)
4-All of the time (5‐7 days)
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
I felt fearful.
1-Rarely or none of the time (less than 1 day)
2-Some or a little of the time (1‐2 days)
3-Occasionally or a moderate amount of time (3‐4 days)
4-All of the time (5‐7 days)
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
My sleep was restless.
1-Rarely or none of the time (less than 1 day)
2-Some or a little of the time (1‐2 days)
3-Occasionally or a moderate amount of time (3‐4 days)
4-All of the time (5‐7 days)
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
I was happy.
1-Rarely or none of the time (less than 1 day)
2-Some or a little of the time (1‐2 days)
3-Occasionally or a moderate amount of time (3‐4 days)
4-All of the time (5‐7 days)
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
I felt lonely.
1-Rarely or none of the time (less than 1 day)
2-Some or a little of the time (1‐2 days)
3-Occasionally or a moderate amount of time (3‐4 days)
4-All of the time (5‐7 days)
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
I could not "get going."
1-Rarely or none of the time (less than 1 day)
2-Some or a little of the time (1‐2 days)
3-Occasionally or a moderate amount of time (3‐4 days)
4-All of the time (5‐7 days)
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
General Anxiety Disorder (GAD)-7
(Interviewer-Administered)
Over the last 2 weeks, how often have you been bothered by the following problems?
Feeling nervous, anxious or on edge
1-Not at all
2-Several days
3-More than half the days
4-Nearly every day
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
2. Not being able to stop or control worrying
1-Not at all
2-Several days
3-More than half the days
4-Nearly every day
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
3. Worrying too much about different things
1-Not at all
2-Several days
3-More than half the days
4-Nearly every day
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
4. Trouble relaxing
1-Not at all
2-Several days
3-More than half the days
4-Nearly every day
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
5. Being so restless that it is hard to sit still
1-Not at all
2-Several days
3-More than half the days
4-Nearly every day
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
6. Becoming easily annoyed or irritable
1-Not at all
2-Several days
3-More than half the days
4-Nearly every day
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
7. Feeling afraid as if something awful might happen
1-Not at all
2-Several days
3-More than half the days
4-Nearly every day
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
VICTIMIZATION
(Interviewer-Administered)
This measure has been adapted from that used with GLBT youth by D'Augelli A, Hershberger SL, Pilkington NW. Lesbian, gay, and bisexual youth and their families: disclosure of sexual orientation and its consequences. American Journal of Orthopsychiatry. 1998;68(3):361-371; discussion 372-365.
How many times have you been verbally insulted (yelled at, criticized) because you are, or were thought to be, transgender?
1 - Never
2 - Once
3 – Twice
– More than twice
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
VICITM1a. If more than twice, fill in number: _____ [Interviewer: Type in numerical response]
How many times have you been threatened with physical violence because you are, or were thought to be, transgender?
1 - Never
2 - Once
3 – Twice
– More than twice
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
VICITM2a If more than twice, fill in number: _____ [Interviewer: Type in numerical response]
How many times have you had an object thrown at you because you are, or were thought to be, transgender?
1 - Never
2 - Once
3 – Twice
4 – More than twice
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
VICITM13a. If more than twice, fill in number: _____ [Interviewer: Type in numerical response]
How many times have you been punched, kicked, or beaten because you are, or were thought to be, transgender?
1 - Never
2 - Once
3 – Twice
4 – More than twice
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
VICITM4a. If more than twice, fill in number: _____ [Interviewer: Type in numerical response]
How many times have you been threatened with a knife, gun or another weapon because you are, or were thought to be, transgender?
1 - Never
2 - Once
3 – Twice
4 – More than twice
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
VICITM5a. If more than twice, fill in number: _____ [Interviewer: Type in numerical response]
How many times have you been attacked sexually (forced to have a sexual experience, raped) because you are, or were thought to be, transgender?
1 - Never
2 - Once
3 – Twice
4 – More than twice
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
VICITM6a. If more than twice, fill in number: _____ [Interviewer: Type in numerical response]
How many times has someone threatened to tell someone else you are transgender?
1 - Never
2 - Once
3 – Twice
4 – More than twice
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
VICITM7a. If more than twice, fill in number: _____ [Interviewer: Type in numerical response]
How many times has someone chased or followed you because you are, or were thought to be, transgender?
1 - Never
2 - Once
3 – Twice
4 – More than twice
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
VICITM8a. If more than twice, fill in number: _____ [Interviewer: Type in numerical response]
How many times has your property been damaged because you are, or were thought to be, transgender?
1 - Never
2 - Once
3 – Twice
4 – More than twice
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
VICITM9a. If more than twice, fill in number: _____ [Interviewer: Type in numerical response]
How many times have you been spat upon (spit at) because you are, or were thought to be, transgender?
1 - Never
2 - Once
3 – Twice
4 – More than twice
99 – Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer the question].
VICITM10a. If more than twice, fill in number: _____ [Interviewer: Type in numerical response]
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Bessler, Patricia (CDC/OID/NCHHSTP) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-20 |
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