Form Approved
OMB No: 0920-0920
Exp. Date: 05/31/2022
Development of Messages for the Let’s Stop HIV Together National Campaign
Attachment 2: Web-based Survey Screener
CDC estimates the average public reporting burden for this collection of information as 2 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, SD-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0920).
We are asking people to be in a research study that will help us learn more about what people think about HIV prevention and testing messages and advertisements. RTI International, a research company in North Carolina is conducting the study. The Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia is funding the research.
If you are eligible and choose to participate in the study, you will receive points redeemable for merchandise.
To see if you are a good match for this study, we will need to ask you some personal questions. Some of the questions will be about your sexual orientation, recent sexual activity, and your HIV status, if you know it. It is your choice to answer the questions. Your answers will be kept private to the extent allowed by law. You can refuse to answer any question or stop at any time.
May we ask you the questions to see if you are a good match for this study?
1 Yes [CONTINUE]
2 No [IMMEDIATELY TERMINATE]
Background Information
S1. How old are you?
Age__________ [INELIGIBLE IF UNDER 18 OR OVER 64]
8 8 Don’t know [INELIGIBLE]
9 9 Prefer not to answer [INELIGIBLE]
S2. What sex were you assigned at birth on your original birth certificate?
1 Male
2 Female
8 8 Don’t know [INELIGIBLE]
99 Prefer not to answer
S3. Do you currently describe yourself as male, female, or transgender?
1 Male
2 Female
3 Transgender
4 None of these
99 Prefer not to answer [INELIGIBLE]
S4. What is the highest level of education you have completed?
1 Grade schoolA
2 Less than high school graduate/some high school
3 High school graduate or completed GED
4 Some college or technical school
5 Received four-year college degree
6 Some post graduate studies
7 Received advanced degree
8 Other [Specify: ]
99 Prefer not to answer
S5. Which of the following best represents how you think of yourself?
1 Gay (lesbian or gay)
2 Straight, that is, not gay (or lesbian or gay)
3 Bisexual
4 Something else
88 I don’t know the answer
99 Prefer not to answer [INELIGIBLE]
S6. Please indicate your race or ethnic background. Are you?
SELECT ONE
Ethnicity
1 Hispanic or Latino
2 Not Hispanic or Latino
SELECT ONE OR MORE
Race
1 African American or Black
2 American Indian or Alaska Native
3 Asian
4 Native Hawaiian or Other Pacific Islander
5 White
S7. Have you ever been tested for HIV? An HIV test checks whether someone has the virus that causes AIDS.
1 Yes
2 No [Skip to S9]
99 Prefer not to answer [INELIGIBLE]
S8. The next question is about the result of your HIV test. What was the result of your most recent HIV test?
1 I tested positive for HIV.
2 I tested negative for HIV.
3 My results were unclear.
88 I never got my results/Don’t know.
9 9 Prefer not to answer [INELIGIBLE]
S9. Did you have vaginal or anal sex in the past [6 months/12 months]?
1 Yes
2 No [INELIGIBLE]
88 Don’t know
99 Prefer not to answer
S10. How often did you and your sexual partner(s) use condoms for sex in the past [6 months/12 months]?
1 Never [Skip S11]
2 Occasionally [Skip S11]
3 Usually [Skip S11]
4 Always
88 Don’t know
99 Prefer not to answer
S11. In the past [6 months/12 months], did you ever, even one time, have sex without a condom?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
S12. Have you had a main sexual partner within the past [6 months/12 months] (that is, a partner you would call your spouse, girlfriend/boyfriend, significant other, or life partner)?
1 Yes
2 No [Skip to S15]
99 Prefer not to answer
S13. Is your main partner male, female, or transgender?
1 Male
2 Female
3 Transgender
4 None of these
99 Prefer not to answer
S14. What is your main partner’s HIV status?
1 My main partner is HIV negative
2 My main partner is HIV positive
3 My main partner has not been tested for HIV
88 Don’t know/my main partner has not told me their HIV status
99 Prefer not to answer
S15. In the past [6 months/12 months], how many casual sexual partners did you have? By casual partner, we mean somebody who you did not consider to be a spouse, girlfriend/boyfriend, significant other, or life partner.
1 0
2 1
3 2-5
4 6-10
5 11-15
6 16-20
7 More than 20
99 Prefer not to answer [INELIGIBLE]
S16. Before today, have you ever heard of people who do not have HIV taking HIV medicines (PrEP: also known as Truvada or Descovy) daily, to keep from getting HIV?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
S17. [HIV-negative only] [Have you ever taken/Are you currently taking] PrEP to prevent getting HIV?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
S18. Have you participated in any other web-based HIV-related surveys in the past [6 months/12 months]?
1 Yes [INELIGIBLE]
2 No
88 Don’t know
99 Prefer not to answer
Thank you for answering these questions. You are eligible to take part in the survey.
Would you like to participate in this survey?
1 Yes [CONTINUE]
2 No [INELIGIBLE]
If ineligible – Closing:
Thank you for answering all of the questions. You are not eligible to be in this study because you did not meet our eligibility criteria. These reasons were decided on earlier by the study team. We value your interest in this study. Thank you for being willing to help us.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Peyton Williams |
| File Modified | 0000-00-00 |
| File Created | 2022-10-25 |