Form Approved
OMB NO.0920-0840
Exp. Date 1/31/2019
ATTACHMENT 5:
EXAMPLE RESPONDENT SURVEY
Public reporting burden of this collection of information is estimated to average 30 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: PRA (0920-0840)
Evaluation Data Collection Instrument
(Includes Baseline Survey, Follow-Up Survey 1 and Follow-Up Survey 2)
Interview Script:
[NOTE: Screener and consent forms will precede the questions below, and contains introductory text about purpose of the survey, as well as providing information for informed consent. Consent form is included in Appendix I.]
Please insert your ID number here. By typing this number and completing the survey, you are volunteering to do this survey.
|
Let’s begin the survey now.
We are interested in your opinion about HIV testing. If you're not sure, choose an answer that comes closest to what you think might be true for each question.
Before we start, are you the only one who can see the questions and your answers?
1. Yes
2. No (GO TO EXIT SCREEN TO ALLOW PARTICIPANT TO CONTINUE ANOTHER TIME)
B. HIV TESTING, BARRIERS, & MOTIVATORS
B1. Have you ever been tested for HIV? Do not count tests you may have had as part of a blood donation. [BASELINE, FU-1, FU-2]
1. Yes
2. No
[IF B1=1, ASK B2-B8 IF B1=2, SKIP TO B6]
Public reporting burden of this collection of information is estimated to average [13 minutes per response for the baseline survey, 15 minutes per response for the first follow-up survey and 5 minutes per response for the second follow-up survey], including the time for reviewing instructions and completing the survey. 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: PRA (0920-0840).
B2. When was your last HIV test? [BASELINE, FU-1, FU-2]
1. 0-2 months ago
2. 3-6 months ago
3. 7-12 months ago
4. More than 12 months ago
B3. Did you get the results of your last HIV test? [BASELINE, FU-1, FU-2]
1. Yes
2. No
[IF B3=1, ASK B4]
B4. What was the result of your last HIV test? [BASELINE, FU-1, FU-2]
1. Positive
2. Negative
3. Have not gotten the results yet
B5. Not including your blood donations, where did you have your last HIV test? [BASELINE, FU-1, FU-2]
1. Private doctor
2. STD or AIDS clinic or testing site
3. Hospital or emergency room
4. Public health department
5. Community health center
6. At home
7. Drug treatment facility
8. Other location
[IF B1=2, ASK B6]
B6. Below is a list of reasons why some people have not been tested for HIV. Which of these are the main reasons why you have not been tested? Please select one or more of the following reasons. [BASELINE, FU-1, FU-2]
[MARK ALL THAT APPLY]
You have not been sexually active
You have not had unprotected sex
3. You were afraid to find out if you were HIV positive
4. You didn’t want to think about HIV or about being HIV positive
5. You didn’t think you were at risk of being HIV positive
6. You don’t like needles
7. You don’t trust the results to be kept private
8. You had to wait too long for the results
9. You didn’t know where to get tested
10. You trust your sex partner
11. You don’t care about the results.
12. You are worried about being labeled as HIV positive.
13. Some other reason [SPECIFY ____________________________]
[IF B1=1, ASK B7]
B7. Which of these are the main reasons for your last HIV test? Please select one or more of the following reasons. [BASELINE, FU-1, FU-2]
[MARK ALL THAT APPY]
1. Just to find out
2. Worried that you are infected
3. A doctor, nurse or other health care provider asked you to
4. The Health Department asked you to
5. Your sex partner asked you to
6. Because of pregnancy
7. To get birth control
8. You found out your sex partner cheated
9. Already had an STD
10.. You were starting a new relationship
11. You get tested during your yearly exam
12. A family member or friend was diagnosed with HIV
13. Other reason [SPECIFY ____________________]
B8. Have you gotten an HIV test since [FILL DATE OF FIRST EXPOSURE TO STIMULI]? [FU-1, FU-2]
1. Yes
2. No
3. DON’T KNOW
4. REFUSED
[IF B8=1, ASK B9]
B9. What was the result of this HIV test? [FU-1, FU-2]
1. Positive
2. Negative
3. Have not gotten the results yet
C. RISKY BEHAVIORS
These next few questions are about your personal behaviors including sexual activity and drug use. Please remember that your answers are kept private.
C1. During the past 12 months, how many people did you have sex with? [BASELINE ONLY]
NUMBER __________________
[If C1=0, skip to C4]
C2. How often did you and your partners use a condom? [BASELINE ONLY]
1. Never
2. Occasionally
3. Usually
4. Always
[IF C2= 4, ASK C3; IF C2=1, 2 or 3, fill C3=1 AND SKIP TO C4]
C3. In the past 12 months, did you ever, even one time, have sex without a condom? [BASELNE ONLY]
Yes
No
C4. Have you ever, even once, injected any drug? [BASELINE ONLY]
1. Yes
2. No
[IF C4=1, ASK C5; IF C4=2 GO TO D1]
C5. In the past 30 days, on how many days did you inject any drug? [BASELINE ONLY]
NUMBER OF DAYS ____________________
[IF C5>=1 DAY, ASK C6]
C6. How many times in the past month have you used a syringe after someone else had already used it? [BASELINE ONLY]
1. No time
2. One time
3. Two times
4. 3 to 5 times
5. 6 to 10 times
6. More than 10 times
D. KNOWLEDGE, ATTITUDES, BELIEFS, & INTENTIONS
Please indicate how much you agree or disagree with the following statements.
D1. There is a test to tell whether a person has HIV. [BASELINE, FU-1, FU-2]
1. True
2. False
3. Don’t know
D2. People can get HIV even though they have had sex with only one person. [BASELINE, FU-1, FU-2]
1. True
2. False
3. Don’t Know
D3. HIV is not my problem. [BASELINE , FU-1, FU-2]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
D4. I should get tested for HIV because I may be at risk. [BASELINE, FU-1, FU-2]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
D5. I don’t think about HIV often. [BASELINE, FU-1, FU-2]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
D6. HIV is not a big problem in my community. [BASELINE, FU-1, FU-2]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
D7. I am less likely than most people to get HIV. [BASELINE, FU-1, FU-2]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
D8. People in my community should get tested for HIV. [BASELINE, FU-1, FU-2]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
D9. People need education to learn how to avoid getting HIV. [BASELINE, FU-1, FU-2]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
D10. There is still no cure for HIV/AIDS. [BASELINE, FU-1, FU-2]
1. True
2. False
3. Don’t Know
D11. I don’t need to worry about getting HIV because I know everything about my boyfriend/partner. [BASELINE, FU-1, FU-2]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
D12. You can tell that somebody has HIV just by looking at them. [BASELINE, FU-1, FU-2]
1. True
2. False
3. Don’t Know
D13. A woman may be at risk for HIV if she had unprotected sex with a man. By unprotected sex, we mean sex without a condom. [BASELINE, FU-1, FU-2]
1. True
2. False
3. Don’t Know
D14. Out of all the women in the U.S. living with AIDS, what percentage would you say are African American? [BASELINE, FU-1, FU-2]
1. 20%
2. 40%
3. 60%
4. 80%
5. Don’t Know
D15. As long as you are in love with someone, you don’t need to worry about getting HIV from them. [BASELINE, FU-1, FU-2]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
D16. Treatment and support programs are available to people in my community who might test positive for HIV. [BASELINE, FU-1, FU-2]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
D17. Knowing my HIV status helps me take responsibility for myself. [BASELINE, FU-1, FU-2]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
D18. Do you know a place where you can get an HIV test? [BASELINE, FU-1, FU-2]
1. Yes
2. No
[IF D18=1, Continue; IF D18=2, Go to 22]
D19. Is this place in your community? [BASELINE, FU-1, FU-2]
1. Yes
2. No
D20. How did you find out about this testing location? [BASELINE, FU-1, FU-2]
[MARK ALL THAT APPY]
1. Called 1-800-CDC-INFO
2. Called another hotline
3. Visited www.hivtest.org
4. Visited another website
5. Friends or family
6. Doctor, nurse, or other health care provider
7. Health department
8. Community health center
9. Church
10. Another organization in my community
11. Other
D21. Do you know a place where you can get a FREE HIV test? [BASELINE, FU-1, FU-2]
1. Yes
2. No
D22. Have you talked to your partner about the importance of getting an HIV test? [BASELINE, FU-1, FU-2]
1. Yes
2. No
D23. How important do you think it is for people to know their HIV status by getting tested? [BASELINE, FU-1, FU-2]
Would you say:
1. Very important
2. Somewhat important
3. Not at all important
Please tell us how much you agree or disagree with the following statement.
D23a. It is important to get tested for HIV so that people who test positive can start getting treated right away.
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
D24. Have you talked to your partner about their HIV status? [BASELINE, FU-1, FU-2]
1. Yes
2. No
HIV Testing Intentions
D25. Do you plan to have a test for HIV in the next 12 months, not including blood donations? [BASELINE, FU-1, FU-2]
1. Definitely yes
2. Probably yes
3. Probably not
4. Definitely not
D26. Do you plan to have a test for HIV in the next 6 months, not including blood donations? [BASELINE, FU-1, FU-2]
1. Definitely yes
2. Probably yes
3. Probably not
4. Definitely not
D27. If a free test was available to see if you have HIV, would you take it? [BASELINE, FU-1, FU-2]
1. Definitely yes
2. Probably yes
3. Probably not
4. Definitely not
D28. When should you get an HIV test after having unprotected sex with a man? [BASELINE, FU-1, FU-2]
1. 0-2 months after having unprotected sex
2. 3-6 months after having unprotected sex
3. 7-12 months after having unprotected sex
4. More than 12 months after having unprotected sex
5. When you start to feel sick
D29. Have you ever talked to anyone, other than your partner, such as friends or family, about getting an HIV test? [BASELINE, FU-1, FU-2]
1. Yes
2. No
MEDIA USE & EXPOSURE TO HEALTH MARKETING
E1. During the past 30 days, have you seen or heard any advertising, campaigns, or messages about…. [BASELINE, FU-1, FU-2]
1. Not using drugs (Yes, No, DK, RF)
2. Quitting smoking (Yes, No, DK, RF)
3. Not starting to smoke (Yes, No, DK, RF)
4. Getting an HIV test (Yes, No, DK, RF)
5. Using condoms to prevent AIDS or sexually transmitted diseases (Yes, No, DK, RF)
6. The importance of knowing whether you or your partner is HIV positive (Yes, No, DK, RF)
7. Not using alcohol (Yes, No, DK, RF)
8. Other (Yes, No, DK, RF)
E2. Have you ever seen or heard of any ads on TV or radio with the following themes or slogans? [BASELINE, FU-1, FU-2]
1. Know HIV/AIDS (Yes, No, DK, RF)
2. Rap it Up (Yes, No, DK, RF)
3. Get tested. Get the results. Get on with your life. (Yes, No, DK, RF)
4. With HIV, Knowledge Is Power (Yes, No, DK, RF)
[TREATMENT CONDITION RESPONDENTS ON POST-BASELINE SURVEYS WILL COMPLETE QUESTIONS E3-E40. ALL OTHER RESPONDENTS/CONDITIONS WILL PROCEED DIRECTLY TO SECTION F.]
The following questions are about a radio ad you heard earlier, entitled “Look Out for Yourself.” To refresh your memory of this ad, we would like to play it for you again.
[PLAY AUDIO 1]:
Please indicate how much you agree or disagree with the following statements about this ad.
E3. This ad was convincing. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E4. This ad said something important to me. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E5. I liked this ad overall. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E6. This ad grabbed my attention. [[FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E7. I learned something new from this ad. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E8. This ad gave me good reasons to get an HIV test. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E9. This ad was confusing. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E10. This ad speaks to me. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E11. I do not like this ad. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
The following questions are about a radio ad you heard earlier, entitled “You Know”. To refresh your memory of this ad, we would like to play it for you again.
[PLAY AUDIO 2]:
Please indicate how much you agree or disagree with the following statements about this ad.
E12. This ad was convincing. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E13. This ad said something important to me. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E14. I liked this ad overall. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E15. This ad grabbed my attention. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E16. I learned something new from this ad. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E17. This ad gave me good reasons to get an HIV test. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E18. This ad was confusing. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E19. This ad speaks to me. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E20. I do not like this ad. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
The following questions are about an image of a billboard ad that you saw earlier, with the message “You know him. But you can’t know everything.” To refresh your memory of this billboard ad, we would like to show it to you again.
[SHOW BILLBOARD AD GRAPHIC]:
Please indicate how much you agree or disagree with the following statements about this billboard ad.
E21. This ad was convincing. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E22. This ad said something important to me. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E23. I liked this ad overall. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E24. This ad grabbed my attention. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E25. I learned something new from this ad. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E26. This ad gave me good reasons to get an HIV test. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E27. This ad was confusing. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E28. This ad speaks to me. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E29. I do not like this ad. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
The following questions are about an informational booklet you read online earlier that contained information about HIV testing. To refresh your memory of the booklet, we would like to show you the booklet’s cover again.
[SHOW BOOKLET COVER]:
Please indicate how much you agree or disagree with the following statements about this booklet.
E30. This booklet was convincing. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E31. This booklet said something important to me. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E32. I liked this booklet overall. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
.
E33. This booklet grabbed my attention. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E34. I learned something new from this booklet. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E35. This booklet gave me good reasons to get an HIV test. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E36. This booklet was confusing. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E37. This booklet speaks to me. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E38. I do not like this booklet. [FU-1 ONLY]
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree
E39. Have you ever visited the website “hivtest.org”? [BASELINE, FU-1, FU-2]
1. Yes
2. No
E40. Have you ever called the CDC-INFO hotline, 1-800-CDC-INFO? [BASELINE , FU-1, FU-2]
1. Yes
2. No
F. BACKGROUND
F1. What is your annual household income from all sources? [BASELINE ONLY]
Less than $20,000
$20,000-$39,999
$40,000-$59,999
$60,000-$69,000
$70,000-$79,000
$80,000 or above
Don’t know
F2. Which of the following statements best describes your current employment situation? [BASELINE ONLY]
Working full-time (35 hours or more a week)
Working part-time (less than 35 hours a week)
Unemployed or laid off
Full-time homemaker
Other
F2a. Are you currently a college student?
Yes
No
F3. At this time, are you living alone or are there others living in your household? Please select one or more. [BASELINE ONLY]
Live Alone
Live with roommate(s)
Live with children
Live with family (e.g., mother, father, sister, aunt, etc.)
Live with partner/boyfriend
Other(s) in household
[If F3=1, skip to F5]
F4. How many children less than 18 years of age live in your household? [BASELINE ONLY]
Number of children_______________
F5. Are you currently covered by any kind of health insurance, that is any policy or program that provides or pays for medical care? [BASELINE ONLY]
Yes
No
[If F5=2, skip to closing]
F6. What type of coverage do you currently have? [CODE ALL THAT APPLY] [BASELINE ONLY]
Private insurance coverage
Medicaid
Medicare
CHAMPUS, or other military coverage
Other__________________________
CLOSING
That was the last question.
For non-panel participants only: If you would like to receive your incentive payment, please click here to provide a name and address where we can mail your check. Your name and address will be kept separate from your answers and will only be used for the purpose of sending your incentive payment.
Thank you for your time and participation in this survey and have a nice day.
| File Type | application/msword |
| File Title | Attachment 2 |
| Author | sxw2 |
| Last Modified By | SYSTEM |
| File Modified | 2018-08-30 |
| File Created | 2018-08-30 |