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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 4d
TLC Follow Up 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)
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Study Trial Questionnaire
Document Version Date: 08/09/2018
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: Acceptability & Satisfaction
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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”]
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What is your highest level of education?
Less than 8th grade
8th grade
Some high school
High school diploma or GED
Trade School Certificate
Some college
Undergraduate degree
Some graduate school
Graduate degree
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
Are you currently a student?
Yes
No
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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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:
Working for pay at a job or business
With a job or business, but currently not working (for example, on a leave of absence)
Looking for work
Working, but not for pay (such as at a family business, internship or volunteering)
Not working and not looking for work
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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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.]
[main occupation response]
What was the approximate start date of this job? (dd/mm/yyyy)
01/01/2017
How many hours per week do you work on average at this job? (hours/week)
35
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)
Yes
No
Don't know [Interviewer: do not read. ONLY select this option if the participant indicates,
"don't know"].
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
Do you have another occupation (job)?
Yes
No
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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What is your other occupation (job)?
[Interviewer: type in response verbatim.]
[other occupation response]
Are you currently in need of help to find a job or in need of job counseling or training?
Yes
No
Refuse [Interviewer: do not read. ONLY select this options 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)?
Yes
No
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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What is the name of the program and/or agency that provided this job-related service?
[Interviewer: type in response verbatim]
[name of program response]
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
Day labor (paid by the day with no promise of additional work)
Selling or dealing drugs
Sex work, survival sex or prostitution
Street income (panhandling, boosting or stealing)
Unemployment benefits
SSI or disability
Food stamps
Income provided by a partner
Income provided by other family members
Income provided by a “sugar daddy”
No income
Student stipend
None of the Above
Under-the-table (“off the books,” not reported to the government by the employer)
Something else; specify [Interviewer: type in response verbatim]
Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer
the question].
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Are you currently in need of legal services or information (check all that apply) to do the
following things:
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?
Something else; specify [Interviewer: type in response verbatim]
Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer
the question].
Did any program or agency provide you with legal services in the past 4 months?
Yes
No
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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What is the name of the program and/or agency that provided you with legal services
[Interviewer: type in response verbatim]
[name of program response]
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In the past 4 months, were you homeless at any time?
Yes
No
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
What is your zip code where you currently live?
[Interviewer: type in 7-digit response]
60640
How long have you lived at your current residence (in # of years and # of months)?
[currant residence response]
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
Something else; specify [Interviewer: type in response verbatim]
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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Are you currently in need of housing services or information?
Yes
No
Refuse [Interviewer: do not read. ONLY select this options 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)?
Yes
No
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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What is the name of the program that provided these housing services?
[Interviewer: type in response verbatim]
[name of program response]
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?
Yes
No
Refuse [Interviewer: do not read. ONLY select this options 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?
Yes
No
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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How long have you been in this relationship? (If you are currently involved in more than
one relationship, select the most significant one).
Less than a month
One month to six months
More than six months to a year
More than a year to three years
More than three years
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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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.
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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.
Have you ever had gender affirming vaginal surgery (vaginoplasty)?
Yes. I have had genital reconstruction. I have a vagina.
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?
Yes
No
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If yes, please let us know now what word you prefer and we will use alternative
language.
[alternative language response]
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The next set of questions will be about the LAST MONTH. Please think back to this
date, and enter something you did or something your family did during that time to help
you remember the last month.
[1 month memory]
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When answering the next questions, please think about the time when you did this, [1
month memory], around this date 07/27/2018, until today.
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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.
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Did you have anal sex in the LAST MONTH?
Yes
No
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How many partners have you had anal (insertive or receptive) sex with in the past
month? This includes sex with or without a condom
4
Total # of anal sex partners in past month
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Total # anal sex partners in past month: 4
How many of these partners were HIV positive? (They told you they were HIV
positive)
02
How many of these partners were HIV negative? (They told you they were HIV
negative)
0
How many of these partners were HIV unknown serostatus? (They did not tell you
their HIV status)
02
Total
4
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How many did you have anal sex with in exchange for things you needed (like money,
drugs, food, shelter, etc.)?
1
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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.
02
Total # of times had receptive anal sex in past month
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Total # times had receptive anal sex in past month while under the influence of
alcohol and/or drugs?
2
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)
2
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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)
2
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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.
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Did you have vaginal sex in the LAST MONTH?
Yes
No
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How many partners have you had vaginal (insertive or receptive) sex with in the
past month? This includes sex with or without a condom.
04
Total # of vaginal sex partners in past month
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Total # vaginal sex partners in past month: 04
How many of these partners were HIV positive? (They told you they were HIV
positive)
02
How many of these partners were HIV negative? (They told you they were HIV
negative)
0
How many of these partners were HIV unknown serostatus? (They did not tell you
their HIV status)
02
Total
4
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How many did you have vaginal sex with in exchange for things you needed (like money,
drugs, food, shelter, etc.)?
1
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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.
02
Total # times you had receptive vaginal sex in past month
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Total # times had receptive vaginal sex in past month while under the influence of
alcohol and/or drugs
2
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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)
2
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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)
2
←
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The next set of questions will be about the LAST 4 months. Please think
back to this date (04/27/2018) and enter something you did or something your family did
during this time to help you remember the last month
[4 month memory]
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When answering the next questions, please think about the time when you did this
([4 month memory]), around this date (04/27/2018), until today.
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Thinking about the LAST 4 MONTHS (from 04/27/2018 until 8/27/2018), please enter the
initials of your LAST sexual partner (someone you’ve had anal or vaginal sex with).
[Last sexual partner
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Thinking about the LAST 4 MONTHS (from 04/27/2018 until 8/27/2018), did you have
another partner in addition to [Last sexual partner initials] (someone you’ve had anal or
vaginal sex with)?
Yes
No
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Please enter the initials of this sexual partner:
[Partner #2 initials]
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Thinking about the LAST 4 MONTHS (from 04/27/2018 until 8/27/2018), did you have
another sex partner in addition to [Last sexual partner initials] and (someone you’ve had
anal or vaginal sex with)?
Yes
No
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Please enter the initials of this sex partner:
[Partner #3 initials]
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We’re going to begin by asking you about your LAST partner, [Last sexual partner
initials].
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What was the HIV status of this partner, [Last sexual partner initials]?
He or she was HIV positive
He or she was HIV negative.
I don't know his/her HIV status.
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How did you find out about this partner’s HIV status?
He or she told me
I found out through another person
I assumed his or her status
Other, please specify
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How would you describe your relationship with this partner, [Last sexual partner initials]?
Serious relationship (boyfriend/girlfriend), someone you dated for awhile and feel very
close to.
Casually dating but not serious
Sleeping with this person (fuck buddy or booty call) but not dating
One night stand
Stranger or anonymous person
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Was this partner, [Last sexual partner initials] a paying (they paid you money for sex) or
trade (you traded food, drugs, shelter, or something else for sex) partner?
Yes
No
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How long have you been with [Last sexual partner initials]?
Less than 1 month
1 to 3 months
4 to 6 months
7 months to 11 months
1 to 3 years
Over 3 years
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How frequently did you drink alcohol before having anal or vaginal sex with this partner,
[Last sexual partner initials]?
Never
Less than half the time
About half the time
More than half the time
Always
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How frequently did you use drugs before having anal or vaginal sex with this partner,
[Last sexual partner initials]?
Never
Less than half the time
About half the time
More than half the time
Always
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What was this partner, [Last sexual partner initials]'s gender?
Male
Female
Transgender (male-to-female)
Transgender (female-to-male)
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In the last 4 months, how many times did you have anal sex with this partner, [Last
sexual partner initials] with you as the bottom (the partner put their penis in your anus or
butt)?
2
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You said you had anal sex with this partner, [Last sexual partner initials] with you as the
bottom this many times during the LAST 4 MONTHS (2). Thinking about those times,
how many times did you use a condom during anal sex with this partner [Last sexual
partner initials]?
0
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In the last 4 months, how many times did you have vaginal sex with this partner, [Last
sexual partner initials] with you as the bottom (the partner put their penis in your vagina)?
2
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You said you had anal sex with this partner, [Last sexual partner initials] with you as the
bottom this many times during the LAST 4 MONTHS (2). Thinking about those times,
how many times did you use a condom during anal sex with this partner [Last sexual
partner initials]?
0
←
→
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Now we are going to ask you about this partner, [Partner #2 initials].
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What was the HIV status of this partner, [Partner #2 initials]?
He or she was HIV positive
He or she was HIV negative.
I don't know his/her HIV status.
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How did you find out about this partner’s HIV status?
He or she told me
I found out through another person
I assumed his or her status
Other, please specify
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How would you describe your relationship with this partner, [Partner #2 initials]?
Serious relationship (boyfriend/girlfriend), someone you dated for awhile and feel very close
to.
Casually dating but not serious
Sleeping with this person (fuck buddy or booty call) but not dating
One night stand
Stranger or anonymous person
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Was this partner, [Partner #2 initials] a paying (they paid you money for sex) or trade (you
traded food, drugs, shelter, or something else for sex) partner?
Yes
No
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How long have you been with [Partner #2 initials]?
Less than 1 month
1 to 3 months
4 to 6 months
7 months to 11 months
1 to 3 years
Over 3 years
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How frequently did you drink alcohol before having anal or vaginal sex with this partner,
[Partner #2 initials]?
Never
Less than half the time
About half the time
More than half the time
Always
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How frequently did you use drugs before having anal or vaginal sex with this partner,
[Partner #2 initials]?
Never
Less than half the time
About half the time
More than half the time
Always
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What was this partner, [Partner #2 initials]'s gender?
Male
Female
Transgender (male-to-female)
Transgender (female-to-male)
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In the last 4 months, how many times did you have anal sex with this partner, [Partner #2
initials] with you as the bottom (the partner put their penis in your anus or butt)?
2
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You said you had anal sex with this partner, [Partner #2 initials] with you as the bottom
this many times during the LAST 4 MONTHS (2). Thinking about those times, how many
times did you use a condom during anal sex with this partner [Partner #2 initials]?
1
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In the last 4 months, how many times did you have vaginal sex with this partner, [Partner
#2 initials] with you as the bottom (the partner put their penis in your vagina)?
2
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You said you had anal sex with this partner, [Partner #2 initials] with you as the bottom
this many times during the LAST 4 MONTHS (2). Thinking about those times, how many
times did you use a condom during vaginal sex with this partner [Partner #2 initials]?
1
←
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Now we are going to ask you about this partner, [Partner #3 initials].
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What was the HIV status of this partner, [Partner #3 initials]?
He or she was HIV positive
He or she was HIV negative.
I don't know his/her HIV status.
←
→
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How would you describe your relationship with this partner, [Partner #3 initials]?
Serious relationship (boyfriend/girlfriend), someone you dated for awhile and feel very
close to.
Casually dating but not serious
Sleeping with this person (fuck buddy or booty call) but not dating
One night stand
Stranger or anonymous person
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Was this partner, [Partner #3 initials] a paying (they paid you money for sex) or trade (you
traded food, drugs, shelter, or something else for sex) partner?
Yes
No
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How long have you been with [Partner #3 initials]?
Less than 1 month
1 to 3 months
4 to 6 months
7 months to 11 months
1 to 3 years
Over 3 years
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How frequently did you drink alcohol before having anal or vaginal sex with this partner,
[Partner #3 initials]?
Never
Less than half the time
About half the time
More than half the time
Always
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How frequently did you use drugs before having anal or vaginal sex with this partner,
[Partner #3 initials]?
Never
Less than half the time
About half the time
More than half the time
Always
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What was this partner, [Partner #3 initials]'s gender?
Male
Female
Transgender (male-to-female)
Transgender (female-to-male)
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In the last 4 months, how many times did you have anal sex with this partner, [Partner #3
initials] with you as the bottom (the partner put their penis in your anus or butt)?
2
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You said you had anal sex with this partner, [Partner #3 initials] with you as the bottom
this many times during the LAST 4 MONTHS (2). Thinking about those times, how many
times did you use a condom during anal sex with this partner [Partner #3 initials]?
0
←
→
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In the last 4 months, how many times did you have vaginal sex with this partner, [Partner
#3 initials] with you as the bottom (the partner put their penis in your vagina)?
2
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You said you had anal sex with this partner, [Partner #3 initials] with you as the bottom
this many times during the LAST 4 MONTHS (2). Thinking about those times, how many
times did you use a condom during vaginal sex with this partner [Partner #3 initials]?
0
←
→
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Thinking about the LAST 4 MONTHS, how many other people have you had vaginal or
anal sex with besides these partners ([Last sexual partner initials], , [Partner #3
initials])? Remember to answer about the LAST 4 MONTHS (from 4/27/2018 until
8/27/2018).
4
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Think of the other sexual partners you’ve had (4 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?
8
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You said you had anal or vaginal sex with other partners besides these 3 partners ([Last
sexual partner initials], , [Partner #3 initials]) this many times during the LAST 4
MONTHS (8). Thinking about those times, how many times did you have sex without
using a condom during anal or vaginal sex with these other partners?
0
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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.
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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.
Have you ever had gender affirming vaginal surgery (vaginoplasty)?
Yes. I have had genital reconstruction. I have a vagina.
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?
Yes
No
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If yes, please let us know now what word you prefer and we will use alternative
language.
[alternative language response]
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The next set of questions will be about the LAST MONTH. Please think back to this
date, and enter something you did or something your family did during that time to help
you remember the last month.
[1 month memory]
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When answering the next questions, please think about the time when you did this, [1
month memory], around this date 07/27/2018, until today.
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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.
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Did you have anal sex in the LAST MONTH?
Yes
No
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How many partners have you had anal (insertive or receptive) sex with in the past
month? This includes sex with or without a condom
4
Total # of anal sex partners in past month
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Total # anal sex partners in past month: 4
How many of these partners were HIV positive? (They told you they were HIV
positive)
02
How many of these partners were HIV negative? (They told you they were HIV
negative)
0
How many of these partners were HIV unknown serostatus? (They did not tell you
their HIV status)
02
Total
4
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How many did you have anal sex with in exchange for things you needed (like money,
drugs, food, shelter, etc.)?
1
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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.
02
Total # of times had receptive anal sex in past month
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Total # times had receptive anal sex in past month while under the influence of
alcohol and/or drugs?
2
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)
2
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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)
4
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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.
02
Total # of times had insertive anal sex in past month
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Total # times had insertive anal sex in past month while under the influence of
alcohol and/or drugs
2
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1/1
8/27/2018
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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)
2
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1/1
8/27/2018
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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)
2
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→
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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.
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Did you have vaginal sex in the LAST MONTH?
Yes
No
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How many partners have you had vaginal (insertive or receptive) sex with in the
past month? This includes sex with or without a condom.
04
Total # of vaginal sex partners in past month
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Total # vaginal sex partners in past month: 04
How many of these partners were HIV positive? (They told you they were HIV
positive)
02
How many of these partners were HIV negative? (They told you they were HIV
negative)
0
How many of these partners were HIV unknown serostatus? (They did not tell you
their HIV status)
02
Total
4
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How many did you have vaginal sex with in exchange for things you needed (like money,
drugs, food, shelter, etc.)?
1
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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.
04
Total # times you had insertive vaginal sex in past month
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Total # times had insertive vaginal sex in past month while under the influence of
alcohol and/or drugs
4
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8/27/2018
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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)
4
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→
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1/1
8/27/2018
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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)
4
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→
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The next set of questions will be about the LAST 4 months. Please think
back to this date (04/27/2018) and enter something you did or something your family did
during this time to help you remember the last month
[4 month memory]
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When answering the next questions, please think about the time when you did this
([4 month memory]), around this date (04/27/2018), until today.
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Thinking about the LAST 4 MONTHS (from 04/27/2018 until 8/27/2018), please enter the
initials of your LAST sexual partner (someone you’ve had anal or vaginal sex with).
[Last partner initials]
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Thinking about the LAST 4 MONTHS (from 04/27/2018 until 8/27/2018), did you have
another partner in addition to [Last partner initials] (someone you’ve had anal or vaginal
sex with)?
Yes
No
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Please enter the initials of this sexual partner:
[partner #2 initials]
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Thinking about the LAST 4 MONTHS (from 04/27/2018 until 8/27/2018), did you have
another sex partner in addition to [Last partner initials] and (someone you’ve had anal or
vaginal sex with)?
Yes
No
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Please enter the initials of this sex partner:
[partner #3 initials]
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We’re going to begin by asking you about your LAST partner, [Last partner initials].
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What was the HIV status of this partner, [Last partner initials]?
He or she was HIV positive
He or she was HIV negative.
I don't know his/her HIV status.
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How did you find out about this partner’s HIV status?
He or she told me
I found out through another person
I assumed his or her status
Other, please specify
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How would you describe your relationship with this partner, [Last partner initials]?
Serious relationship (boyfriend/girlfriend), someone you dated for awhile and feel very
close to.
Casually dating but not serious
Sleeping with this person (fuck buddy or booty call) but not dating
One night stand
Stranger or anonymous person
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Was this partner, [Last partner initials] a paying (they paid you money for sex) or trade
(you traded food, drugs, shelter, or something else for sex) partner?
Yes
No
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How long have you been with [Last partner initials]?
Less than 1 month
1 to 3 months
4 to 6 months
7 months to 11 months
1 to 3 years
Over 3 years
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How frequently did you drink alcohol before having anal or vaginal sex with this partner,
[Last partner initials]?
Never
Less than half the time
About half the time
More than half the time
Always
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How frequently did you use drugs before having anal or vaginal sex with this partner, [Last
partner initials]?
Never
Less than half the time
About half the time
More than half the time
Always
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What was this partner, [Last partner initials]'s gender?
Male
Female
Transgender (male-to-female)
Transgender (female-to-male)
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In the LAST 4 MONTHS, how many times did you have anal sex with this partner, [Last
partner initials] with you as the top (you put your penis in his or her anus or butt)?
1
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You said you had anal sex with this partner, [Last partner initials] with you as the top this
many times during the LAST 4 MONTHS (1). Thinking about those times, how many
times did you use a condom during anal sex with this partner [Last partner initials]?
0
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In the last 4 months, how many times did you have anal sex with this partner, [Last
partner initials] with you as the bottom (the partner put their penis in your anus or butt)?
1
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You said you had anal sex with this partner, [Last partner initials] with you as the bottom
this many times during the LAST 4 MONTHS (1). Thinking about those times, how many
times did you use a condom during anal sex with this partner [Last partner initials]?
0
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→
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In the LAST 4 MONTHS, how many times did you have vaginal sex with this partner,
[Last partner initials] with you as the top (you put your penis in his or her vagina)?
1
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You said you had vaginal sex with this partner, [Last partner initials] with you as the top
this many times during the LAST 4 MONTHS (1). Thinking about those times, how many
times did you use a condom during anal sex with this partner [Last partner initials]?
1
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Now we are going to ask you about this partner, [partner #2 initials].
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What was the HIV status of this partner, [partner #2 initials]?
He or she was HIV positive
He or she was HIV negative.
I don't know his/her HIV status.
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How did you find out about this partner’s HIV status?
He or she told me
I found out through another person
I assumed his or her status
Other, please specify
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How would you describe your relationship with this partner, [partner #2 initials]?
Serious relationship (boyfriend/girlfriend), someone you dated for awhile and feel very close
to.
Casually dating but not serious
Sleeping with this person (fuck buddy or booty call) but not dating
One night stand
Stranger or anonymous person
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Was this partner, [partner #2 initials] a paying (they paid you money for sex) or trade (you
traded food, drugs, shelter, or something else for sex) partner?
Yes
No
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How long have you been with [partner #2 initials]?
Less than 1 month
1 to 3 months
4 to 6 months
7 months to 11 months
1 to 3 years
Over 3 years
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How frequently did you drink alcohol before having anal or vaginal sex with this partner,
[partner #2 initials]?
Never
Less than half the time
About half the time
More than half the time
Always
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How frequently did you use drugs before having anal or vaginal sex with this partner,
[partner #2 initials]?
Never
Less than half the time
About half the time
More than half the time
Always
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What was this partner, [partner #2 initials]'s gender?
Male
Female
Transgender (male-to-female)
Transgender (female-to-male)
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In the LAST 4 MONTHS, how many times did you have anal sex with this partner,
[partner #2 initials] with you as the top (you put your penis in his or her anus or butt)?
1
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You said you had anal sex with this partner, [partner #2 initials] with you as the top this
many times during the LAST 4 MONTHS (1). Thinking about those times, how many
times did you use a condom during anal sex with this partner [partner #2 initials]?
0
←
→
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In the last 4 months, how many times did you have anal sex with this partner, [partner #2
initials] with you as the bottom (the partner put their penis in your anus or butt)?
1
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You said you had anal sex with this partner, [partner #2 initials] with you as the bottom
this many times during the LAST 4 MONTHS (1). Thinking about those times, how many
times did you use a condom during anal sex with this partner [partner #2 initials]?
0
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In the LAST 4 MONTHS, how many times did you have vaginal sex with this partner,
[partner #2 initials] with you as the top (you put your penis in his or her vagina)?
1
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You said you had vaginal sex with this partner, [partner #2 initials] with you as the top this
many times during the LAST 4 MONTHS (1). Thinking about those times, how many
times did you use a condom during vaginal sex with this partner [partner #2 initials]?
0
←
→
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Now we are going to ask you about this partner, [partner #3 initials].
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What was the HIV status of this partner, [partner #3 initials]?
He or she was HIV positive
He or she was HIV negative.
I don't know his/her HIV status.
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How would you describe your relationship with this partner, [partner #3 initials]?
Serious relationship (boyfriend/girlfriend), someone you dated for awhile and feel very
close to.
Casually dating but not serious
Sleeping with this person (fuck buddy or booty call) but not dating
One night stand
Stranger or anonymous person
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Was this partner, [partner #3 initials] a paying (they paid you money for sex) or trade (you
traded food, drugs, shelter, or something else for sex) partner?
Yes
No
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How long have you been with [partner #3 initials]?
Less than 1 month
1 to 3 months
4 to 6 months
7 months to 11 months
1 to 3 years
Over 3 years
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How frequently did you drink alcohol before having anal or vaginal sex with this partner,
[partner #3 initials]?
Never
Less than half the time
About half the time
More than half the time
Always
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How frequently did you use drugs before having anal or vaginal sex with this partner,
[partner #3 initials]?
Never
Less than half the time
About half the time
More than half the time
Always
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What was this partner, [partner #3 initials]'s gender?
Male
Female
Transgender (male-to-female)
Transgender (female-to-male)
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In the LAST 4 MONTHS, how many times did you have anal sex with this partner,
[partner #3 initials] with you as the top (you put your penis in his or her anus or butt)?
1
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You said you had anal sex with this partner, [partner #3 initials] with you as the top this
many times during the LAST 4 MONTHS (1). Thinking about those times, how many
times did you use a condom during anal sex with this partner [partner #3 initials]?
0
←
→
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In the last 4 months, how many times did you have anal sex with this partner, [partner #3
initials] with you as the bottom (the partner put their penis in your anus or butt)?
1
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You said you had anal sex with this partner, [partner #3 initials] with you as the bottom
this many times during the LAST 4 MONTHS (1). Thinking about those times, how many
times did you use a condom during anal sex with this partner [partner #3 initials]?
0
←
→
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In the LAST 4 MONTHS, how many times did you have vaginal sex with this partner,
[partner #3 initials] with you as the top (you put your penis in his or her vagina)?
1
←
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You said you had vaginal sex with this partner, [partner #3 initials] with you as the top this
many times during the LAST 4 MONTHS (1). Thinking about those times, how many
times did you use a condom during vaginal sex with this partner [partner #3 initials]?
0
←
→
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Thinking about the LAST 4 MONTHS, how many other people have you had vaginal or
anal sex with besides these partners ([Last partner initials], , [partner #3 initials])?
Remember to answer about the LAST 4 MONTHS (from 4/28/2018 until 8/28/2018).
4
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Think of the other sexual partners you’ve had (4 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?
4
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You said you had anal or vaginal sex with other partners besides these 3 partners ([Last
partner initials], , [partner #3 initials]) this many times during the LAST 4 MONTHS (4).
Thinking about those times, how many times did you have sex without using a condom
during anal or vaginal sex with these other partners?
4
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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.
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How interested are you in taking a PrEP medication to help prevent HIV infection?
Very interested
Somewhat interested
Somewhat uninterested
Very uninterested
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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Have you taken PrEP in the last 4 months?
Yes
No
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Have you taken PrEP in the past month?
Yes
No
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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Yes
Place Bookmark
No
8/20/2018
8/19/2018
8/18/2018
8/17/2018
8/16/2018
8/15/2018
8/14/2018
In the calendar [SHOW CARD], please indicate whether or not you have taken PrEP on
each day during the past month, beginning with yesterday.
Yes
No
8/13/2018
8/12/2018
8/11/2018
8/10/2018
8/9/2018
8/8/2018
8/7/2018
In the calendar [SHOW CARD], please indicate whether or not you have taken PrEP on
each day during the past month, beginning with yesterday.
Yes
No
8/6/2018
8/5/2018
8/4/2018
8/3/2018
8/2/2018
8/1/2018
7/31/2018
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In the past 4 months, how many times have you seen a provider for PrEP care and
follow-up?
[Interviewer: type in numerical response]
1
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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?
Yes
No
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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At what age did you begin taking hormones?
[Interviewer: Enter age in two-digit numerical value]
16
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How many times in the last 4 months have you taken hormones?
[Interviewer: Enter age in two-digit numerical value]
20
In the last 4 months, where did you usually get your hormones? (Check all that apply)
From a clinic or health center
From a private doctor, private practice or HMO
On the street (dealer or doctor practicing illegally/black market)
From a lover or sex partner
From a friend
Something else, specify [Interviewer: type response verbatim]
Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer
the question].
Have you ever injected silicone?
Yes
No
Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to answer
the question].
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Where have you injected silicone? (Check all that apply)
In your cheeks, chin or face
In your hips or buttocks
In your breasts
Somewhere else, specify [Interviewer: type response verbatim]
Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to
answer the question].
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).
None – never had any surgery/laser therapy
Breast implants (breast augmentation)
Facial or neck surgery (for example, nose job, cheek implants, forehead lift, etc.)
Vaginal surgery (vaginoplasty)
Somewhere else, please specify [Interviewer: type response verbatim]
[other;specified]
Refuse [Interviewer: do not read. ONLY select this option if the participant refuses to
answer the question].
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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
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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How comfortable are you with going out in public during the day?
Not at all comfortable
Slightly comfortable
Moderately comfortable
Very comfortable
Extremely comfortable
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
How comfortable are you with people knowing that you are transgender?
Not at all comfortable
Slightly comfortable
Moderately comfortable
Very comfortable
Extremely comfortable
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answer the question]
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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
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
How satisfied are you with your current level of femininity?
Not at all satisfied
Slightly satisfied
Moderately satisfied
Very satisfied
Extremely satisfied
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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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.
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I am a worthy member of the transgender community that I belong to.
Strongly
Disagree
Disagree
Disagree
somewhat
Neutral
Agree
somewhat
Agree
Strongly
Agree
Agree
Strongly
Agree
Agree
Strongly
Agree
I often regret that I belong to the transgender community.
Strongly
Disagree
Disagree
Disagree
somewhat
Neutral
Agree
somewhat
Overall, the transgender community is considered good by others.
Strongly
Disagree
Disagree
Disagree
somewhat
Neutral
Agree
somewhat
Overall, my membership in the transgender community has very little to do with how I feel
about myself.
Strongly
Disagree
Disagree
Disagree
somewhat
Neutral
←
Agree
somewhat
Agree
Strongly
Agree
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I feel I don’t have much to offer to the transgender community that I belong to.
Strongly
Disagree
Disagree
Disagree
somewhat
Neutral
Agree
somewhat
Agree
Strongly
Agree
In general, I’m glad to be a member of the transgender community that I belong to.
Strongly
Disagree
Disagree
Disagree
somewhat
Neutral
Agree
somewhat
Agree
Strongly
Agree
Most people consider the transgender community, on the average, to be more ineffective
than other communities or social groups.
Strongly
Disagree
Disagree
Disagree
somewhat
Neutral
Agree
somewhat
Agree
Strongly
Agree
The transgender community that I belong to is an important reflection of who I am.
Strongly
Disagree
Disagree
Disagree
somewhat
Neutral
←
Agree
somewhat
Agree
Strongly
Agree
→
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I am a cooperative participant in the transgender community that I belong to.
Strongly
Disagree
Disagree
Disagree
somewhat
Neutral
Agree
somewhat
Agree
Strongly
Agree
Overall, I often feel that the transgender community of which I am a member is not
worthwhile.
Strongly
Disagree
Disagree
Disagree
somewhat
Neutral
Agree
somewhat
Agree
Strongly
Agree
In general, others respect the transgender community that I am a member of.
Strongly
Disagree
Disagree
Disagree
somewhat
Neutral
Agree
somewhat
Agree
Strongly
Agree
The transgender community that I belong to is unimportant to my sense of what kind of a
person I am.
Strongly
Disagree
Disagree
Disagree
somewhat
Neutral
←
Agree
somewhat
Agree
Strongly
Agree
→
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I often feel I’m a useless member of the transgender community.
Strongly
Disagree
Disagree
Disagree
somewhat
Neutral
Agree
somewhat
Agree
Strongly
Agree
Agree
Strongly
Agree
I feel good about the transgender community that I belong to.
Strongly
Disagree
Disagree
Disagree
somewhat
Neutral
Agree
somewhat
In general, others think that the transgender community that I am a member of is unworthy.
Strongly
Disagree
Disagree
Disagree
somewhat
Neutral
Agree
somewhat
Agree
Strongly
Agree
In general, belonging to the transgender community is an important part of my self-image.
Strongly
Disagree
Disagree
Disagree
somewhat
Neutral
←
Agree
somewhat
Agree
Strongly
Agree
→
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The next set of questions are about support you may have received 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…
None of the time
A little of the time
Some of the time
Most of the time
All of the time
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
To help with daily chores if you are sick? Would you say…
None of the time
A little of the time
Some of the time
Most of the time
All of the time
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answer the question]
To get together with you for relaxation? Would you say…
None of the time
A little of the time
Some of the time
Most of the time
All of the time
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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To understand your problems? Would you say…
None of the time
A little of the time
Some of the time
Most of the time
All of the time
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
To love you and make you feel wanted? Would you say…
None of the time
A little of the time
Some of the time
Most of the time
All of the time
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
To borrow money from when you need it? Would you say…
None of the time
A little of the time
Some of the time
Most of the time
All of the time
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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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.
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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.)
2. Alcoholic beverages
(beer, wine, spirits, etc.)
3. Cannabis (marijuana, pot,
grass, hash, etc.)
4. Cocaine (coke, crack,
etc.)
5. Amphetamine type
stimulants (speed, diet pills,
ecstasy, etc.)
6. Inhalants (nitrous, glue,
petrol, paint thinner, etc.)
7. Sedatives or Sleeping
Pills (Valium, Serepax,
Rohypnol, etc.)
8. Hallucinogens (LSD, acid,
mushrooms, PCP, Special
K, etc.)
9. Opioids (heroin,
morphine, methadone,
codeine, etc.)
10. Other – specify:
[other; specified]
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Question 2: In the past three months, how often have you used the substances you
mentioned?
Never
Once or
Twice
Monthly
Weekly
Daily or
Almost Daily
1. Tobacco products
(cigarettes, chewing
tobacco, cigars, etc.)?
2. Alcoholic beverages
(beer, wine, spirits,
etc.)?
3. Cannabis
(marijuana, pot, grass,
hash, etc.)?
4. Cocaine (coke,
crack, etc.)?
5. Amphetamine type
stimulants (speed, diet
pills, ecstasy, etc.)?
6. Inhalants (nitrous,
glue, petrol, paint
thinner, etc.)?
7. Sedatives or
Sleeping Pills (Valium,
Serepax, Rohypnol,
etc.)?
8. Hallucinogens (LSD,
acid, mushrooms, PCP,
Special K, etc.)?
9. Opioids (heroin,
morphine, methadone,
codeine, etc.)?
10. [other; specified]
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Question 3: During the past three months, how often have you had a strong desire or
urge to use
Never
Once or
Twice
Monthly
Weekly
Daily or
Almost Daily
1. Tobacco products
(cigarettes, chewing
tobacco, cigars, etc.)?
2. Alcoholic beverages
(beer, wine, spirits,
etc.)?
3. Cannabis
(marijuana, pot, grass,
hash, etc.)?
4. Cocaine (coke,
crack, etc.)?
5. Amphetamine type
stimulants (speed, diet
pills, ecstasy, etc.)?
6. Inhalants (nitrous,
glue, petrol, paint
thinner, etc.)?
7. Sedatives or
Sleeping Pills (Valium,
Serepax, Rohypnol,
etc.)?
8. Hallucinogens (LSD,
acid, mushrooms, PCP,
Special K, etc.)?
9. Opioids (heroin,
morphine, methadone,
codeine, etc.)?
10. [other; specified]
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Question 4: During the past three months, how often has your use of (FIRST DRUG,
SECOND DRUG, etc.) 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.)?
2. Alcoholic beverages
(beer, wine, spirits,
etc.)?
3. Cannabis
(marijuana, pot, grass,
hash, etc.)?
4. Cocaine (coke,
crack, etc.)?
5. Amphetamine type
stimulants (speed, diet
pills, ecstasy, etc.)?
6. Inhalants (nitrous,
glue, petrol, paint
thinner, etc.)?
7. Sedatives or
Sleeping Pills (Valium,
Serepax, Rohypnol,
etc.)?
8. Hallucinogens (LSD,
acid, mushrooms, PCP,
Special K, etc.)?
9. Opioids (heroin,
morphine, methadone,
codeine, etc.)?
10. [other; specified]
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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.)
Never
Once or
Twice
Monthly
Weekly
Daily or
Almost Daily
1. Tobacco products
(cigarettes, chewing
tobacco, cigars, etc.)?
2. Alcoholic beverages
(beer, wine, spirits,
etc.)?
3. Cannabis
(marijuana, pot, grass,
hash, etc.)?
4. Cocaine (coke,
crack, etc.)?
5. Amphetamine type
stimulants (speed, diet
pills, ecstasy, etc.)?
6. Inhalants (nitrous,
glue, petrol, paint
thinner, etc.)?
7. Sedatives or
Sleeping Pills (Valium,
Serepax, Rohypnol,
etc.)?
8. Hallucinogens (LSD,
acid, mushrooms, PCP,
Special K, etc.)?
9. Opioids (heroin,
morphine, methadone,
codeine, etc.)?
10. [other; specified]
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Question 6: Has a friend or relative or anyone else ever expressed concern about your
use of (FIRST DRUG, SECOND DRUG, etc. )
No, Never
Yes, in the past 3
months
Yes, but not in the past
3 months
1. Tobacco products
(cigarettes, chewing
tobacco, cigars, etc.)?
2. Alcoholic beverages
(beer, wine, spirits,
etc.)?
3. Cannabis
(marijuana, pot, grass,
hash, etc.)?
4. Cocaine (coke,
crack, etc.)?
5. Amphetamine type
stimulants (speed, diet
pills, ecstasy, etc.)?
6. Inhalants (nitrous,
glue, petrol, paint
thinner, etc.)?
7. Sedatives or
Sleeping Pills (Valium,
Serepax, Rohypnol,
etc.)?
8. Hallucinogens (LSD,
acid, mushrooms, PCP,
Special K, etc.)?
9. Opioids (heroin,
morphine, methadone,
codeine, etc.)?
10. [other; specified]
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Question 7: Have you ever tried and failed to control, cut down or stop using (FIRST
DRUG, SECOND DRUG, etc. )
No, Never
Yes, in the past 3
months
Yes, but not in the past
3 months
1. Tobacco products
(cigarettes, chewing
tobacco, cigars, etc.)?
2. Alcoholic beverages
(beer, wine, spirits,
etc.)?
3. Cannabis
(marijuana, pot, grass,
hash, etc.)?
4. Cocaine (coke,
crack, etc.)?
5. Amphetamine type
stimulants (speed, diet
pills, ecstasy, etc.)?
6. Inhalants (nitrous,
glue, petrol, paint
thinner, etc.)?
7. Sedatives or
Sleeping Pills (Valium,
Serepax, Rohypnol,
etc.)?
8. Hallucinogens (LSD,
acid, mushrooms, PCP,
Special K, etc.)?
9. Opioids (heroin,
morphine, methadone,
codeine, etc.)?
10. [other; specified]
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Question 8: Have you ever used any drug by injection?
(NON-MEDICAL USE ONLY - Not prescribed your health care provider)
No, Never
Yes in the past 3 months
Yes, but not in the past 3 months
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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.
Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or moderate amount of time (3-4 days)
All of the time (5-7 days)
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
I had trouble keeping my mind on what I was doing.
Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or moderate amount of time (3-4 days)
All of the time (5-7 days)
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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I felt depressed.
Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or moderate amount of time (3-4 days)
All of the time (5-7 days)
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
I felt that everything I did was an effort.
Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or moderate amount of time (3-4 days)
All of the time (5-7 days)
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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I felt hopeful about the future.
Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or moderate amount of time (3-4 days)
All of the time (5-7 days)
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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I felt fearful.
Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or moderate amount of time (3-4 days)
All of the time (5-7 days)
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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My sleep was restless.
Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or moderate amount of time (3-4 days)
All of the time (5-7 days)
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
I was happy.
Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or moderate amount of time (3-4 days)
All of the time (5-7 days)
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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I felt lonely.
Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or moderate amount of time (3-4 days)
All of the time (5-7 days)
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
I could not "get going."
Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or moderate amount of time (3-4 days)
All of the time (5-7 days)
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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Over the last 2 weeks, how often have you been bothered by the following problems?
Feeling nervous, anxious or on edge
Not at all
Several days
More than half the days
Nearly every day
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
Not being able to stop or control worrying
Not at all
Several days
More than half the days
Nearly every day
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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Worrying too much about different things
Not at all
Several days
More than half the days
Nearly every day
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
Trouble relaxing
Not at all
Several days
More than half the days
Nearly every day
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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Being so restless that it is hard to sit still
Not at all
Several days
More than half the days
Nearly every day
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
Becoming easily annoyed or irritable
Not at all
Several days
More than half the days
Nearly every day
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
Feeling afraid as if something awful might happen
Not at all
Several days
More than half the days
Nearly every day
Refuse [Interviewer: do not read. ONLY select this options if the participant refuses to
answer the question]
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Please help us improve our program by answering some questions about the TLC program.
We are interested in your opinions, whether they are positive or negative. Please circle one
response to each question.
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How would you rate the quality of TLC program?
Very Good
Good
Poor
Very poor
Did the TLC program meet your expectations?
Yes
No
To what extent has the TLC program met your needs?
All of my needs have been met
Some of my needs have been met
None of my needs have been met
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If a friend were interested in the TLC program, would you recommend it to them?
Yes
No
Was the TLC program useful to you?
Yes
No
If you were to seek help again, would you come back to the TLC program?
Yes
No
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Very
Dissatisfied
Draft
.
.
.
Place Bookmark
Very
Satisfied
How satisfied are you
with the amount of
information you
received
How satisfied are you
with the TLC program
overall
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Please decide how much you agree or disagree with the following statements. Select one
response for each item.
Strongly
Disagree
Disagree
Neutral
Agree
Strongly
Agree
The TLC program
helped me to establish
positive friendships
with other trans
women
I learned useful
information from the
TLC program
The TLC program
helped me get better
connected to the
transgender
community
The TLC program
increased my desire to
access other services
and programs for trans
women
I liked the activities we
completed in the TLC
program
The TLC program
helped me to
understand things that
might cause me to
engage in unhealthy
behavior like having
unsafe sex
The topics we covered
in the TLC program
applied to my life
The TLC program
helped me to create
positive goals for
myself
The TLC program
helped me feel about
about my future
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Would you recommend the TLC program to other trans women?
Yes
No
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Do you have any other feedback about the TLC program?
[feedback response]
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In the past 4 months, in addition to participation in the TransLife Center (TLC), have you
participated in other HIV prevention programs or studies?
Yes
No
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If yes, which ones? Specify:
[Interviewer: type in response verbatim]
[Interviewer: If in doubt about which programs/studies may be HIV-related, err on the
side of caution and include them.]
[other studies; specified]
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The participant has used PrEP at least 4 times/week for every sequential week. A hair
sample and release of information for PrEP care engagement should be collected.
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We thank you for your time spent taking this survey.
Your response has been recorded.
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| File Type | application/pdf |
| File Modified | 2018-08-28 |
| File Created | 2018-08-28 |