Att 3r: HIV Communication and Awareness Brief Survey Instrument

Form Approved

OMB No: 0920-1169

Exp. Date: 03/31/2020

Development of CDC’s Let’s Stop HIV Together Social Marketing Campaign for Consumers

Attachment 3r: HIV Communication and Awareness

Brief Survey Instrument

Public reporting burden of this collection of information is estimated to average 15 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 (0920-1169).

Attachment 3c: HIV Communication and Awareness

Brief Survey Instrument

CASE ID_____________

PARTICIPANT SURVEY

We are interested in your opinions about HIV communication and awareness. We would also like to get some additional information about you. If you’re not sure, choose an answer that comes closest to what you think might be true for each question. Please remember that your answers are private. You can choose not to answer any question and can stop at any time. When you are finished with the survey, please place it in the envelope.

Sexual Orientation and Gender Identity

1. What is your current gender identity? (Select ALL that apply)

₁ Male

₂ Female

₃ Transgender Male/Transman/FTM

₄ Transgender Female/Transwoman/MTF

₅ Genderqueer

₆ Another category [Specify: ]

₉ Prefer not to answer [TERMINATE AND GO TO CLOSING]

2. What sex were you assigned at birth? Mark only one.

₁ Male

₂ Female

₉₉ Prefer not to answer [TERMINATE AND GO TO CLOSING]

3. Which do you consider yourself to be?

₁ Gay or homosexual

₂ Bisexual

₃ Straight or heterosexual

₄ Queer

₅ Pansexual

₆ Another category [Specify:___________________________________________]

₈₈ Don’t know

₉₉ Prefer not to answer [TERMINATE AND GO TO CLOSING]

Sources of Information

The first set of questions asks about how you may get certain kinds of information.

4. Please tell us whether you’d be interested in getting information about HIV prevention from each of the following sources. Mark all that apply.

.

	Yes	No
Community health clinic	1	2
Doctor’s office	1	2
Church	1	2
Community center	1	2
Health fair	1	2
Work	1	2
Sporting event	1	2
Night club	1	2
Advertisements in shopping malls	1	2
Coffee shop	1	2
Clothing store	1	2
Health club or gym	1	2
Government services office (e.g., social services, DMV)	1	2
College campuses	1	2
Newspaper	1	2
Magazine	1	2
Radio advertisement	1	2
Television advertisement	1	2
Billboard	1	2
Bus or train stop advertisement	1	2
Social networking sites or mobile app (e.g., Facebook, Twitter)	1	2
Dating or hook up sites or app (e.g., [INSERT EXAMPLE])	1	2
Text message to your cell phone	1	2
Health websites	1	2
[INSERT OTHER SOURCE]	1	2
[INSERT OTHER SOURCE]	1	2
[INSERT OTHER SOURCE]	1	2
[INSERT OTHER SOURCE]	1	2
[INSERT OTHER SOURCE]	1	2

₈₈ Don’t know

₉₉ Prefer not to answer

5. Do you use the Internet?

₁ Yes

₂ No (GO TO Q10)

₈₈ Don’t know

₉₉ Prefer not to answer

6. How do you access the internet? Mark all that apply.

₁ Computer

₂ Mobile phone

₃ Tablet

₄ Other [Specify: __________________________________________________]

₈₈ Don’t know

₉₉ Prefer not to answer

7. In an average month, how often do you…

	Daily	2 -5 Times a Week	Once a Week	2-3 Times a Month	Once a Month	Less than Once a Month	Never	Don’t know	Prefer not to answer
use Facebook? (www.facebook.com)	1	2	3	4	5	6	7	88	99
use Twitter? (www.twitter.com)	1	2	3	4	5	6	7	88	99
use YouTube? (www.youtube.com)	1	2	3	4	5	6	7	88	99
use dating/hook-up sites or mobile apps? (e.g., [INSERT EXAMPLE])	1	2	3	4	5	6	7	88	99
visit online news websites? (e.g., cnn.com, slate.com, etc.)	1	2	3	4	5	6	7	88	99
watch television?	1	2	3	4	5	6	7	88	99
listen to the radio?	1	2	3	4	5	6	7	88	99
use buses, subways, or trains?	1	2	3	4	5	6	7	88	99
read magazines?	1	2	3	4	5	6	7	88	99
read newspapers?	1	2	3	4	5	6	7	88	99

8. What other websites or mobile services that you use on a daily basis? Enter your response.

₈₈ Don’t know

₉₉ Prefer not to answer

8. In an average month, how often do you use the following dating or hook-up sites or mobile apps?

	Daily	2 -5 Times a Week	Once a Week	2-3 Times a Month	Once a Month	Less than Once a Month	Never	Don’t know	Prefer not to answer
Match	1	2	3	4	5	6	7	88	99
Tinder	1	2	3	4	5	6	7	88	99
Adam4Adam	1	2	3	4	5	6	7	88	99
Grindr	1	2	3	4	5	6	7	88	99
[INSERT OTHER SITE]	1	2	3	4	5	6	7	88	99
[INSERT OTHER SITE]	1	2	3	4	5	6	7	88	99
[INSERT OTHER SITE]	1	2	3	4	5	6	7	88	99
[INSERT OTHER SITE]	1	2	3	4	5	6	7	88	99
[INSERT OTHER SITE]	1	2	3	4	5	6	7	88	99
[INSERT OTHER SITE]	1	2	3	4	5	6	7	88	99
[INSERT OTHER SITE]	1	2	3	4	5	6	7	88	99
[INSERT OTHER SITE]	1	2	3	4	5	6	7	88	99
Other [Specify______________]	1	2	3	4	5	6	7	88	99

[IF Q3=3, GO TO Q11]

10. In the past [INSERT #] months, how many times have you attended a Pride event (e.g. Gay, Lesbian, Transgender Pride event)?

₁ ______

₈₈ Don’t know

₉₉ Prefer not to answer

10. Before being contacted for this study, had you ever heard of CDC or the Centers for Disease Control and Prevention?

₁ Yes

₂ No

₈₈ Don’t know

₉₉ Prefer not to answer

10. In the last [INSERT #] months, how often have you…

	Very often	Often	Some-times	Rarely	Never	Don’t know	Prefer not to answer
looked for information about [HIV/HIV testing/HIV prevention/other topic]?	1	2	3	4	5	88	99
talked about [HIV/HIV testing/HIV prevention/other topic]?	1	2	3	4	5	88	99
visited a Centers for Disease Control website for HIV information?	1	2	3	4	5	88	99

13. Please tell us if you agree or disagree with the following statement: I trust the CDC as a source of [health/HIV] information.

₁ Strongly agree

₂ Agree

₃ Neither disagree nor agree

₄ Disagree

₅ Strongly disagree

₈₈ Don’t know

₉₉ Prefer not to answer

HIV Awareness and Knowledge

13. On a scale from 1 to 10, where 1 is the least important and 10 is the most important, how would you rate the importance of HIV as a health problem facing the nation today?

Least Important									Most Impor-tant	Don’t know	Prefer not to answer
 1	 2	 3	 4	 5	 6	 7	 8	 9	 10	88	99

13. Please tell me how much you agree or disagree with the following statements.

	Strongly Agree	Agree	Disagree	Strongly Disagree	Don’t Know	Prefer not to answer
AIDS is not at all serious; it is like having the common cold.	1	2	3	4	88	99
HIV is not my problem.	1	2	3	4	88	99
There are medications available to treat HIV.	1	2	3	4	88	99
I should get tested for HIV because I may be at risk.	1	2	3	4	88	99
HIV is not a big problem in my community.	1	2	3	4	88	99
I am less likely than most people to get HIV.	1	2	3	4	88	99
People in my community should get tested for HIV.	1	2	3	4	88	99
I don’t need to worry about getting HIV because I know everything about my [boyfriend/partner/partners].	1	2	3	4	88	99
As long as you are in love with someone, you don’t need to worry about getting HIV from them.	1	2	3	4	88	99
Treatment and support programs are available to people [in my community/like me] who might test positive for HIV.	1	2	3	4	88	99
Because of new treatments for HIV, I think [people/HIV negative men] are taking more sexual risks.	1	2	3	4	88	99
Because of new treatments for HIV, I’m more willing to have unprotected sex with someone who is HIV negative.	1	2	3	4	88	99
Because of new treatments for HIV, I’m more willing to have unprotected sex with someone who is HIV positive.	1	2	3	4	88	99

Personal Relevance of HIV/AIDS

13. Bearing in mind the different ways people can be infected with HIV, how concerned are you about you, personally, becoming infected with HIV?

₁ Very concerned

₂ Somewhat concerned

₃ Not too concerned

₄ Not at all concerned

₈₈ Don’t know

₉₉ Prefer not to answer

13. How concerned are you about a son or daughter who is 21 years of age or younger becoming infected with HIV?

₁ Very concerned

₂ Somewhat concerned

₃ Not too concerned

₄ Not at all concerned

₅ I do not have a son or daughter under the age of 21

₈₈ Don’t know

₉₉ Prefer not to answer

13. Do you personally know anyone who now has AIDS, has died from AIDS, or has tested positive for HIV?

₁ Yes

₂ No [GO TO Q20]

₈₈ Don’t know [GO TO Q20]

₉₉ Prefer not to answer [GO TO Q20]

13. Is that a family member, a close friend, an acquaintance or coworker, or someone else?

₁ Yes, close friend or family member

₂ Yes, acquaintance or coworker

₃ Someone else

₈₈ Don’t know

₉₉ Prefer not to answer

HIV Communication Intentions and Behaviors

13. I plan to talk to [INSERT PERSON] about [INSERT TOPIC] within the next [INSERT TIMEFRAME].

₁ Strongly agree

₂ Agree

₄ Disagree

₅ Strongly disagree

₈₈ Don’t know

₉₉ Prefer not to answer

13. I plan to [tweet/post a status update and/or comment on Facebook/blog/send an SMS text message] about [INSERT TOPIC] within the next [INSERT TIMEFRAME].

₁ Strongly agree

₂ Agree

₄ Disagree

₅ Strongly disagree

_{8 8} Don’t know

₉₉ Prefer not to answer

13. How likely are you to [talk/tweet/post a status update/comment on Facebook/blog/ send an SMS message about topic] within the next [INSERT TIMEFRAME]?

₁ Very unlikely

₂ Unlikely

₃ Neither likely nor unlikely

₄ Likely

₅ Very Likely

₈₈ Don’t know

₉₉ Prefer not to answer

13. In the past [INSERT #] months, how often have you discussed the following topics with your sexual partners?

	Never	Occa- sionally	Usually	Always	Don’t know	Prefer not to Answer
Number of prior sexual partners	1	2	3	4	88	99
HIV status	1	2	3	4	88	99
HIV testing history	1	2	3	4	88	99
Drug and alcohol use	1	2	3	4	88	99
Places where you have met sexual partners	1	2	3	4	88	99
History of sexually transmitted infections (STI)	1	2	3	4	88	99
Using condoms	1	2	3	4	88	99
Different sexual positions based on HIV status	1	2	3	4	88	99
Taking drugs to treat HIV infection (e.g., antiretroviral therapy or ART)	1	2	3	4	88	99
Taking medicines daily to reduce the chance of being HIV infected (e.g., Truvada, pre-exposure prophylaxis, or PrEP)	1	2	3	4	88	99
Taking medicines after sex to reduce the chance of being HIV infected (e.g., post‑exposure prophylaxis, nPEP)	1	2	3	4	88	99
[INSERT HIV TOPIC]	1	2	3	4	88	99

13. How likely is it that you will discuss the following topics with your next sexual partner before engaging in any sexual activities?

	Very Unlikely	Some-what Unlikely	Neither Unlikely nor Likely	Some-what Likely	Very Likely	Don’t know	Prefer not to Answer
Number of prior sexual partners	1	2	3	4	5	88	99
HIV status	1	2	3	4	5	88	99
HIV testing history	1	2	3	4	5	88	99
Drug and alcohol use	1	2	3	4	5	88	99
Places where you have met sexual partners	1	2	3	4	5	88	99
History of sexually transmitted infections (STI)	1	2	3	4	5	88	99
Using condoms	1	2	3	4	5	88	99
Different sexual positions based on HIV status	1	2	3	4	5	88	99
Taking drugs to treat HIV infection (e.g., antiretroviral therapy or ART)	1	2	3	4	5	88	99
Taking medicines daily to reduce the chance of being HIV infected (e.g., Truvada, pre-exposure prophylaxis, or PrEP)	1	2	3	4	5	88	99
Taking medicines after sex to reduce the chance of being HIV infected (e.g., post‑exposure prophylaxis, nPEP)	1	2	3	4	5	88	99
[INSERT HIV TOPIC]	1	2	3	4	5	88	99

13. How often would you say that your friends and other people close to you discuss the following topics with their sexual partners?

	Never	Occa-sionally	Usually	Always	Don’t know	Prefer not to Answer
Number of prior sexual partners	1	2	3	4	88	99
HIV status	1	2	3	4	88	99
HIV testing history	1	2	3	4	88	99
Drug and alcohol use	1	2	3	4	88	99
Places where you have met sexual partners	1	2	3	4	88	99
History of sexually transmitted infections (STI)	1	2	3	4	88	99
Using condoms	1	2	3	4	88	99
Different sexual positions based on HIV status	1	2	3	4	88	99
Taking drugs to treat HIV infection (e.g., antiretroviral therapy or ART)	1	2	3	4	88	99
Taking drugs used to treat HIV infection to reduce chances of being HIV infected (e.g., non-occupational post-exposure prophylaxis [nPEP] or pre-exposure prophylaxis [PrEP])	1	2	3	4	88	99
[INSERT HIV TOPIC]	1	2	3	4	88	99

13. How sure are you that you could discuss the following topics with your next sexual partner before engaging in any sexual activities?

	Very Unsure I Could	Some-what Unsure I Could	Neither Unsure nor Sure I Could	Some-what Sure I Could	Very Sure I Could	Don’t know	Prefer not to Answer
Number of prior sexual partners	1	2	3	4	5	88	99
HIV status	1	2	3	4	5	88	99
HIV testing history	1	2	3	4	5	88	99
Drug and alcohol use	1	2	3	4	5	88	99
Places where you have met sexual partners	1	2	3	4	5	88	99
History of sexually transmitted infections (STI)	1	2	3	4	5	88	99
Using condoms	1	2	3	4	5	88	99
Different sexual positions based on HIV status	1	2	3	4	5	88	99
Taking drugs to treat HIV infection (e.g., antiretroviral therapy or ART)	1	2	3	4	5	88	99
Taking drugs used to treat HIV infection to reduce chances of being HIV infected (e.g., non-occupational post-exposure prophylaxis [nPEP] or pre-exposure prophylaxis [PrEP])	1	2	3	4	5	88	99
[INSERT HIV TOPIC]	1	2	3	4	5	88	99

13. In this next section, please tell us how much you agree or disagree with the following statements. Here, “disclose” means sharing your HIV status with other people.

	Strongly Agree	Agree	Neither Disagree nor Agree	Disa-gree	Strongly Disagree	Don’t know	Prefer not to Answer
Most of my sexual partners disclose their HIV status.	1	2	3	4	5	88	99
Most [people/gay or bisexual men/transgender people] I know disclose their HIV status.	1	2	3	4	5	88	99
Disclosing your HIV status is difficult.	1	2	3	4	5	88	99
Disclosing my HIV status allows me to have unprotected sex with partners who are the same HIV status as me.	1	2	3	4	5	88	99
I plan to disclose my HIV status the next time I have sex.	1	2	3	4	5	88	99

13. Please tell us how much you disagree or agree with the following statements.

	Strongly Agree	Agree	Neither Agree nor Disa-gree	Disa-gree	Strongly Disagree	Don’t know	Prefer not to Answer
Most [people/gay or bisexual men/transgender people] I know choose to have sex only with people who have the same HIV status.	1	2	3	4	5	88	99
Choosing to have sex only with people who have the same HIV status as me is difficult.	1	2	3	4	5	88	99
I intend to have sex only with people who have the same HIV status as me.	1	2	3	4	5	88	99

29. Please tell us how much you disagree or agree with the following statements.

	Strongly Agree	Agree	Neither Agree nor Disa-gree	Disa-gree	Strongly Disagree	Don’t know	Prefer not to Answer
It is important to talk about [INSERT HIV TOPIC].	1	2	3	4	5	88	99
It is important to talk about [INSERT HIV TOPIC] with [INSERT PERSON].	1	2	3	4	5	88	99
I am confident that I can talk to [INSERT PERSON] about [INSERT HIV TOPIC].	1	2	3	4	5	88	99

30. In the past [INSERT TIMEFRAME], how and with whom have you talked about HIV? Mark all that apply.

	Partner	Friends	Family
Face-to-face	1	2	3
Facebook—personal page	1	2	3
Facebook—[INSERT CAMPAIGN] fan page	1	2	3
Twitter	1	2	3
SMS text messages	1	2	3
Blog	1	2	3

₈₈ Don’t know

₉₉ Prefer not to answer

30. In the past [INSERT TIMEFRAME], have you talked to [INSERT PERSON] about [INSERT HIV TOPIC]?

₁ Yes

₂ No [GO TO Q33]

_{8 8} Don’t know [GO TO Q33]

₉₉ Prefer not to answer [GO TO Q33]

30. In the past [INSERT TIMEFRAME], how often have you talked to [INSERT PERSON] about [INSERT HIV TOPIC]?

₁ Never

₂ Once

₃ 2 to 3 times

₄ 4 to 5 times

₅ 6 to 10 times

₆ More than 10 times

₈₈ Don’t know

₉₉ Prefer not to answer

30. In the past [INSERT TIMEFRAME], have you [tweeted/retweeted/replied to a tweet] about [INSERT HIV TOPIC]?

₁ Yes

₂ No [GO TO Q35]

_{8 8} Don’t know [GO TO Q35]

₉₉ Prefer not to answer [GO TO Q35]

30. In the past [INSERT TIMEFRAME], how often have you [tweeted/retweeted/replied to a tweet] about [INSERT HIV TOPIC]

₁ Never

₂ Once

₃ 2 to 3 times

₄ 4 to 5 times

₅ 6 to 10 times

₆ More than 10 times

_{8 8} Don’t know

₉₉ Prefer not to answer

30. In the past [INSERT TIMEFRAME], have you posted a Facebook status update or commented on Facebook about [INSERT HIV TOPIC]?

₁ Yes

₂ No [GO TO Q37]

₈₈ Don’t know [GO TO Q37]

₉₉ Prefer not to answer [GO TO Q37]

30. In the past [INSERT TIMEFRAME], how often have you posted a Facebook update or commented on Facebook about [INSERT HIV TOPIC]?

₁ Never

₂ Once

₃ 2 to 3 times

₄ 4 to 5 times

₅ 6 to 10 times

₆ More than 10 times

_{8 8} Don’t know

₉₉ Prefer not to answer

30. Have you ever posted a comment on the [INSERT CAMPAIGN] Facebook fan page?

₁ Yes

₂ No [GO TO Q39]

₈₈ Don’t know [GO TO Q39]

₉₉ Prefer not to answer [GO TO Q39]

30. How often have you posted a comment on the [INSERT CAMPAIGN] Facebook fan page?

₁ Never

₂ Once

₃ 2 to 3 times

₄ 4 to 5 times

₅ 6 to 10 times

₆ More than 10 times

_{8 8} Don’t know

₉₉ Prefer not to answer

30. In the past [INSERT TIMEFRAME], have you posted a blog or commented on a blog post about [INSERT HIV TOPIC]?

₁ Yes

₂ No [GO TO Q41]

_{8 8} Don’t know [GO TO Q41]

₉₉ Prefer not to answer [GO TO Q41]

30. In the past [INSERT TIMEFRAME], how often have you posted a blog or commented on a blog post about [INSERT HIV TOPIC]?

₁ Never

₂ Once

₃ 2 to 3 times

₄ 4 to 5 times

₅ 6 to 10 times

₆ More than 10 times

_{8 8} Don’t know

₉₉ Prefer not to answer

30. In the past [INSERT TIMEFRAME], have you forwarded an SMS text message about [INSERT HIV TOPIC]?

₁ Yes

₂ No [GO TO Q43]

_{8 8} Don’t know [GO TO Q43]

₉₉ Prefer not to answer [GO TO Q43]

30. In the past [INSERT TIMEFRAME], how often have you forwarded an SMS text message about [INSERT HIV TOPIC]?

₁ Never

₂ Once

₃ 2 to 3 times

₄ 4 to 5 times

₅ 6 to 10 times

₆ More than 10 times

₈₈ Don’t know

₉₉ Prefer not to answer

30. In the past [INSERT TIMEFRAME], have you sent an SMS text message about [INSERT HIV TOPIC]?

₁ Yes

₂ No [GO TO Q45]

_{8 8} Don’t know [GO TO Q45]

₉₉ Prefer not to answer [GO TO Q45]

30. In the past [INSERT TIMEFRAME], how often have you sent SMS text messages about [INSERT HIV TOPIC]?

₁ Never

₂ Once

₃ 2 to 3 times

₄ 4 to 5 times

₅ 6 to 10 times

₆ More than 10 times

_{8 8} Don’t know

₉₉ Prefer not to answer

Comfort with Social Media Discourse about HIV

30. My [INSERT PERSON] thinks I should [talk/tweet/post a status update or comment on Facebook/blog/send an SMS text message/etc.] about HIV.

₁ Strongly agree

₂ Agree

₄ Disagree

₅ Strongly disagree

_{8 8} Don’t know

₉₉ Prefer not to answer

30. Think about the people who are important to you. Do most of them think that you should, or should not, [talk/tweet/post a status update or comment on Facebook/blog/send an SMS text message/etc.] about HIV?

₁ Definitely should not

₂ Should not

₃ Neither should nor should not

₄ Should

₅ Definitely should

_{8 8} Don’t know

₉₉ Prefer not to answer

30. How do you think [INSERT PERSON] would feel about you [talking/tweeting/posting status updates or commenting on Facebook/blogging/sending SMS text messages/etc.] about HIV?

₁ Strongly disapprove

₂ Disapprove

₃ Neither approve nor disapprove

₄ Approve

₅ Strongly approve
_{8 8} Don’t know

₉₉ Prefer not to answer

30. How many of your [INSERT PEOPLE] do you think have [talked/tweeted/posted a status update or commented on Facebook/blogged/sent an SMS text message/etc.] about HIV in the last [INSERT TIMEFRAME]?

₁ None

₂ A few

₃ Some

₄ Most

₅ All

₈₈ Don’t know

₉₉ Prefer not to answer

30. When it comes to [talking/tweeting/posting status updates or commenting on Facebook/ blogging/sending SMS text messages/etc.] about HIV, I want to do what my [INSERT PERSON] want(s) me to do.

₁ Strongly agree

₂ Agree

₃ Neither disagree nor agree

₄ Disagree

₅ Strongly disagree

₈₈ Don’t know

₉₉ Prefer not to answer

30. I am confident that I can [tweet/post a status update and/or comment on Facebook/blog/send an SMS text message] about [INSERT HIV TOPIC].

₁ Strongly agree

₂ Agree

₄ Disagree

₅ Strongly disagree

₈₈ Don’t know

₉₉ Prefer not to answer

Attitudes toward Talking about HIV

30. Please tell us how much you agree or disagree with the following statements.

	Strongly Agree	Agree	Neither Disa-gree nor Agree	Disa-gree	Strongly Disagree	Don’t know	Prefer not to Answer
It is important to talk about HIV with your main sexual partner, like a boyfriend, girlfriend, significant other, or spouse.	1	2	3	4	5	88	99
I am confident that I can talk to my main sexual partner about HIV.	1	2	3	4	5	88	99
It is important to talk about HIV with your [casual/non-main] [female/male] sexual partners.	1	2	3	4	5	88	99
It is important to talk about HIV with your family.	1	2	3	4	5	88	99
I am confident that I can talk to my family about HIV.	1	2	3	4	5	88	99
It is important to talk about HIV with your friends.	1	2	3	4	5	88	99
I am confident that I can talk to my friends about HIV.	1	2	3	4	5	88	99
It is important to talk about HIV with your health care provider.	1	2	3	4	5	88	99
I am confident that I can talk to my health care provider about HIV.	1	2	3	4	5	88	99

[IF Q1≠1 AND Q2≠1 AND Q3=3, GO TO CLOSING]

[IF Q2≠3, GO TO CLOSING]

Sexual Orientation, Gender Identity, and Discrimination

30. Have you ever told anyone that you are [attracted to or have sex with men/transgender people]?

₁ Yes

₂ No

₈₈ Don’t know

₉₉ Prefer not to answer

30. Which of the following people have you told that you are [attracted to or have sex with men/transgender]?

	Yes	No	Don’t know	Prefer not to Answer
Gay, lesbian, bisexual, or transgender friends	1	2	88	99
Friends who are not gay, lesbian, bisexual, or transgender	1	2	88	99
Family members	1	2	88	99
Health care providers	1	2	88	99
A religious or spiritual leader such as a priest or minister	1	2	88	99

30. During the past [INSERT #] months, how often have any of the following things happened to you because someone knew or assumed you were [attracted to men/transgender]?

	Never	Occasionally	Usually	Always	Don’t know	Prefer not to Answer
You were called names or insulted	1	2	3	4	88	99
You received poorer services than other people in restaurants, stores, other businesses or agencies	1	2	3	4	88	99
You were treated unfairly at work or school	1	2	3	4	88	99
You were denied or given lower quality health care	1	2	3	4	88	99
You were physically attacked or injured	1	2	3	4	88	99

30. How strongly do you agree or disagree with the following statement: “Most people in my neighborhood are tolerant of [gay and bisexual/transgender] people.”

₁ Strongly agree

₂ Agree

₃ Neither agree nor disagree

₄ Disagree

₅ Strongly disagree

₈₈ Don’t know

₉₉ Prefer not to answer

The End

Thank you for answering these questions. Please place the survey in the envelope provided. Give the survey and your consent form to the interviewer when you go into the interview room. The interviewer will not see your responses to these questions.

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