Form Approved
OMB No 0920-XXXX
OMB Exp. Date: XX/XX/XXXX
National HIV Behavioral Surveillance System - Brief Biobehavioral HIV Assessments (NHBS-BHBA)
Attachment #3c (English)
Quantitative Core Survey (English)
Public reporting burden of this collection of information is estimated to average 10 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 30329; Attn: OMB-PRA (0920-XXXX)
CONSENT INFORMATION
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If base eligibility = yes and population eligibility = MSM, HET, PWID |
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Question: Do you agree to take part in the interview? |
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Variable: CONSENTA |
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Response: Consent to survey |
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No…0 |
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Yes…1 |
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If CONSENTA = yes |
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Question: Do you agree to HIV counseling and testing? |
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Variable: CONSENTB |
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Response: Consent to HIV testing |
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No…0 |
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Yes…1 |
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(INTERVIEWER: if you did NOT offer the person hepatitis testing, enter ‘not offered”) |
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Question: Do you agree to hepatitis testing? |
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Variable: CNSTHEP1 |
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Response: Consent to hepatitis testing |
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No…0 |
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Yes…1 |
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Not offered…2 |
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(INTERVIEWER: if you did NOT offer the person STI testing, enter ‘not offered”) |
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Question: Do you agree to STD testing? |
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Variable: CNSTSTI1 |
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Response: Consent to STD testing |
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No…0 |
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Yes…1 |
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Not offered…2 |
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If CONSENTB = yes or CNSTHEP1 = yes or CNSTSTI1 = yes |
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Question: Do you agree to let us store some of your test sample(s) for future testing? |
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Variable: CNSTSTORE |
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Response: Consent to specimen storage |
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No…0 |
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Yes…1 |
DEMOGRAPHICS
Question Set Intro: Now I am going to ask you questions about yourself. [Variable: qsintro_c] |
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Question: What is the highest level of education you completed? [Do NOT read choices] |
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Variable: SCHOOL |
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Response: Education |
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Never attended school…1 |
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Grades 1 through 8…2 |
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Grades 9 through 11…3 |
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Grade 12 or GED…4 |
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Some college, Associate's Degree, or Technical Degree…5 |
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Bachelor's Degree…6 |
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Any post graduate studies…7 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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Question: Do you currently have health insurance or health care coverage? |
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Variable: CURRHLTH1 |
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Response: Currently insured |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If currently insured, go to next question. |
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Question: What kind of health insurance or health care coverage do you currently have? You may choose more than one option. [Give respondent Flashcard B] [Read choices. Check all that apply] |
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Variable: TYPE_INS |
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Response: Type of health insurance |
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A private health plan- purchased through an employer or purchased directly…0 |
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Medicaid- for people with low incomes…1 |
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Medicare- for the elderly and people with disabilities ….2 |
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Indian Health Service…3 |
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TRICARE/CHAMPUS…4 |
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Veterans Administration coverage…5 |
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Some other government plan…6 |
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Some other health insurance…7 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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Question: In the past 12 months, that is, since [fill with interview month] of last year, have you seen a doctor, nurse, or other health care provider? |
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Variable: VISITMD12 |
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Response: Health care visit, past 12 months |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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Question: During the past 12 months, was there any time when you needed medical care but didn't get it because you couldn't afford it? |
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Variable: HCAFF |
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Response: Lacked health care due to cost |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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Introduction: The next questions are about your overall health. [Variable: qsintro_d] |
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Question: Are you deaf or do you have serious difficulty hearing? |
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Variable: DISDEAF |
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Response: Disability- Hearing |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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Question: Are you blind or do you have serious difficulty seeing, even when wearing glasses? |
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Variable: DISBLND |
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Response: Disability- Vision |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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Question: Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? |
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Variable: DISCOGN |
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Response: Disability- Cognition |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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Question: Do you have serious difficulty walking or climbing stairs? |
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Variable: DISWALK |
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Response: Disability- Ambulation |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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Question: Do you have difficulty dressing or bathing? |
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Variable: DISCARE |
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Response: Disability- Self-care |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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Question: Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone, such as visiting a doctor's office or shopping? |
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Variable: DISERND |
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Response: Disability- Errands |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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SEX BEHAVIORS
Intro: The next questions are about having sex. Please remember your answers will be kept private. |
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If SEX12=yes and SXGENDER=men and GEND=male
QUESTION: “In the past 12 months, that is, since [fill with interview month] of last year, with how many different men have you had oral or anal sex?” [variable: intro_sbm]
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If SEX12=yes and SXGENDER=men and GEND=female
QUESTION: “In the past 12 months, that is, since [fill with interview month] of last year, with how many different men have you had oral, vaginal or anal sex?” [variable: intro_sbf] |
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Variable: SEX12_M |
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Response: Number of male sex partners, past 12 mos. |
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Range…1-7000 |
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Note: If Don’t Know or Refuse to Answer, leave it blank. |
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If SEX12=yes and SXGENDER=women |
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Question: In the past 12 months, that is, since [fill with interview month] of last year, with how many different women have you had oral, vaginal, or anal sex? |
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Variable: SEX12_F |
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Response: Number of female sex partners, past 12 mos. |
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Range…1-7000 |
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Note: If Don’t Know or Refuse to Answer, leave it blank. |
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If SEX12=yes and SEX12_M=1
Intro: Now I'm going to ask you about the 1 male sex partner you had in the past 12 months. [intro_mm] |
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If SEX12=yes and SEX12_M=1 and GEND=female |
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Question: In the past 12 months, did you have vaginal sex with him? |
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Variable: F_VS_M1 |
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Response: VS partner - 12 months |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SEX12_M=1 and GEND=female and F_VS_M1=Yes |
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Question: In the past 12 months, did you have vaginal sex with him without using a condom? |
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Variable: F_UVS_M1 |
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Response: UVS partner - 12 months |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SEX12_M=1 |
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Question: In the past 12 months, did you have anal sex with him? |
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Variable: AS_M1 |
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Response: AS partner - 12 months |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SEX12_M=1 and AS_M1=yes |
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Question: In the past 12 months, did you have anal sex with him without using a condom? |
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Variable: UAS_M1 |
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Response: UAS partner - 12 months |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SEX12_M=1 |
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Question: In the past 12 months, did this man give you money, drugs, or some other type of payment or trade to have sex with him? |
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Variable: EXCH_R_M1 |
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Response: Single exchange received (M sex partner) |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SEX12_M=1 |
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Question: In the past 12 months, did you give this man money, drugs, or some other type of payment or trade in exchange for having sex with you? |
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Variable: EXCH_G_M1 |
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Response: Single exchange give (M sex partner) |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SEX12_M=2 or more
Intro: Now I'm going to ask you about the [fill with #] male sex partners you had in the past 12 months. [intro_mms] |
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If SEX12=yes and SEX12_M=2 or more and GEND=female |
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Question: In the past 12 months, with how many of these [fill with # male sex partners] men did you have vaginal sex? |
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Variable: F_VS_M |
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Response: Number of VS partners - 12 months |
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Range…0-7000 |
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Note: If Don’t Know or Refuse to Answer, leave it blank. |
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If SEX12=yes and SEX12_M=2 or more and GEND=female and F_VS_M=2 or more |
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Question: In the past 12 months, with how many of these [fill with # male vaginal sex partners] men did you have vaginal sex without using a condom? |
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Variable: F_UVS_M |
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Response: Number of UVS partners - 12 months |
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Range…0-7000 |
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Note: If Don’t Know or Refuse to Answer, leave it blank. |
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If SEX12=yes and SEX12_M=2 or more and GEND=female and F_VS_M=1 |
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Question: In the past 12 months, did you have vaginal sex with him without using a condom? |
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Variable: F_UVS_M1A |
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Response: UVS partner - 12 months |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SEX12_M=2 or more |
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Question: In the past 12 months, with how many of these [fill with # male sex partners] men did you have anal sex? |
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Variable: AS_M |
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Response: Number of AS partners - 12 months |
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Range…0-7000 |
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Note: If Don’t Know or Refuse to Answer, leave it blank. |
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If SEX12=yes and SEX12_M=2 or more and AS_M=2 or more |
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Question: In the past 12 months, with how many of these [fill with # male anal sex partners] men did you have anal sex without using a condom? |
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Variable: UAS_M |
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Response: Number of UAS partners - 12 months |
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Range…0-7000 |
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Note: If Don’t Know or Refuse to Answer, leave it blank. |
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If SEX12=yes and SEX12_M=2 or more and AS_M=1 |
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Question: In the past 12 months, did you have anal sex with him without using a condom? |
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Variable: UAS_M1A |
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Response: UAS partner - 12 months |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SEX12_M=2 or more |
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Question: Of your [fill with # male sex partners] male sex partners in the past 12 months, did any of them give you money, drugs, or some other type of payment or trade to have sex with them? |
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Variable: EXCH_R_M |
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Response: Multiple exchange received (M sex partner) |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SEX12_M=2 or more |
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Question: Of your [fill with # male sex partners] male sex partners in the past 12 months, did you give any of them money, drugs, or some other type of payment or trade in exchange for having sex with you? |
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Variable: EXCH_G_M |
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Response: Multiple exchange give (M sex partner) |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SXGENDER=women and GEND=male
Intro: Now I'm going to ask you about the [fill with #] female sex partners you had in the past 12 months. (ASK ONLY MALE RESPONDENTS) [variable: intro_ff] |
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If SEX12=yes and SEX12_F=1 |
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Question: In the past 12 months, did you have vaginal sex with her? |
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Variable: VS_F1 |
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Response: VS partner - 12 months |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SEX12_F=1 and VS_F1=Yes |
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Question: In the past 12 months, did you have vaginal sex with her without using a condom? |
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Variable: UVS_F1 |
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Response: UVS partner - 12 months |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SEX12_F=1 |
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Question: In the past 12 months, did you have anal sex with her? |
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Variable: AS_F1 |
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Response: AS partner - 12 months |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SEX12_F=1 and AS_F1=Yes |
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Question: In the past 12 months, did you have anal sex with her without using a condom? |
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Variable: UAS_F1 |
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Response: UAS partner - 12 months |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SEX12_F=1 |
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Question: In the past 12 months, did you give this woman money, drugs, or some other type of payment or trade in exchange for having sex with you? |
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Variable: EXCH_G_F1 |
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Response: Single exchange give (F sex partner) |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SEX12_F=1 |
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Question: In the past 12 months, did this woman give you money, drugs, or some other type of payment or trade to have sex with her? |
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Variable: EXCH_R_F1 |
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Response: Single exchange received (F sex partner) |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SEX12_F=2 or more |
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Question: In the past 12 months, with how many of these [fill with # female sex partners] women did you have vaginal sex? |
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Variable: VS_F |
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Response: Number of VS partners - 12 months |
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Range…0-7000 |
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Note: If Don’t Know or Refuse to Answer, leave it blank. |
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If SEX12=yes and SEX12_F=2 or more and VS_F=2 or more |
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Question: In the past 12 months, with how many of these [fill with # female vaginal sex partners] women did you have vaginal sex without using a condom? |
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Variable: UVS_F |
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Response: Number of UVS partners - 12 months |
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Range…0-7000 |
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Note: If Don’t Know or Refuse to Answer, leave it blank. |
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If SEX12=yes and SEX12_F=2 or more and VS_F=1 |
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Question: In the past 12 months, did you have vaginal sex with her without using a condom? |
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Variable: UVS_F1A |
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Response: UVS partner - 12 months |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SEX12_F=2 or more |
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Question: In the past 12 months, with how many of these [fill with # female sex partners] women did you have anal sex? |
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Variable: AS_F |
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Response: Number of AS partners - 12 months |
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Range…0-7000 |
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Note: If Don’t Know or Refuse to Answer, leave it blank. |
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If SEX12=yes and SEX12_F=2 or more and AS_F=2 or more |
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Question: In the past 12 months, with how many of these [fill with # female anal sex partners] women did you have anal sex without using a condom? |
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Variable: UAS_F |
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Response: Number of UAS partners - 12 months |
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Range…0-7000 |
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Note: If Don’t Know or Refuse to Answer, leave it blank. |
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If SEX12=yes and SEX12_F=2 or more and AS_F=1 |
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Question: In the past 12 months, did you have anal sex with her without using a condom? |
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Variable: UAS_F1A |
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Response: UAS partner - 12 months |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SEX12_F=2 or more |
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Question: Of your [fill with # female sex partners] female sex partners in the past 12 months, did you give any of them money, drugs, or some other type of payment or trade in exchange for having sex with you? |
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Variable: EXCH_G_F |
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Response: Multiple exchange give (F sex partner) |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SEX12_F=2 or more |
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Question: Of your [fill with # female sex partners] female sex partners in the past 12 months, did any of them give you money, drugs, or some other type of payment or trade to have sex with them? |
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Variable: EXCH_R_F |
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Response: Multiple exchange received (F sex partner) |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SXGENDER=men and GEND=female Intro: The next questions are about the last time you had either oral, vaginal or anal sex with a man. [variable: intro_female] |
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If SEX12=yes and SXGENDER=men and GEND=male Intro: The next questions are about the last time you had either oral or anal sex with a man. [variable: intro_man] |
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If SEX12=yes and SEX12_M=1 or more |
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Question: How many days or weeks or months ago was that? |
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Variable: LSTSXN_M |
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Response: Last oral/vaginal/anal sex with man |
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Range…0-365 (if today, enter "0") |
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Note: If Don’t Know or Refuse to Answer, leave it blank. |
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[Interviewer: Was this days or weeks or months?] |
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Variable: LSTSXU_M |
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Response: Last oral/vaginal/anal sex with man |
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Days…0 |
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Weeks…1 |
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Months…2 |
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If SEX12=yes and SEX12_M=1 or more |
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Question: The last time you had sex with this partner, did you know his HIV status? |
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Variable: LPKNWSTS_M |
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Response: Knew male partner HIV status at last event |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If LPKNWSTS_M=yes |
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Question: What was his HIV status? [Do NOT read choices] |
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Variable: LPHIVSTS_M |
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Response: Partner HIV status at last event |
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HIV-negative, that is, he does NOT have HIV…1 |
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HIV-positive, that is, he does have HIV…2 |
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Indeterminate…3 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SEX12_M=1 or more |
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Question: As far as you know, did he ever inject drugs like heroin, cocaine, or meth? |
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Variable: LPIDU_M |
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Response: last male partner ever injected |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SEX12_M=1 or more and GEND=female |
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Question: As far as you know, has he ever had sex with other men? |
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Variable: LPMSM_M |
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Response: last male partner ever MSM |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If SEX12=yes and SXGENDER=women and GEND=male
Intro: The next questions are about the last time you had oral, vaginal, or anal sex with a woman. (ASK ONLY MALE RESPONDENTS) [variable: intro_mnf] |
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If SEX12=yes and SEX12_F=1 or more |
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Question: How many days or weeks or months ago was that? |
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Variable: LSTSXN_F |
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Response: Last oral, vaginal, anal sex with woman |
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Range…0-365 (if today, enter "0") |
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Note: If Don’t Know or Refuse to Answer, leave it blank. |
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[Interviewer: Was this days or weeks or months?] |
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Variable: LSTSXU_F |
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Response: Last oral/vaginal/anal sex with man |
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Days…0 |
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Weeks…1 |
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Months…2 |
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If SEX12=yes and SEX12_F=1 or more |
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Question: The last time you had sex with this partner, did you know her HIV status? |
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Variable: LPKNWSTS_F |
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Response: Knew female partner HIV status at last event |
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No…0 |
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Yes…1 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
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If LPKNWSTS_F=yes |
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Question: What was her HIV status? [Do NOT read choices] |
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Variable: LPHIVSTS_F |
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Response: Partner HIV status at last event |
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HIV-negative, that is, she does NOT have HIV…1 |
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HIV-positive, that is, she does have HIV…2 |
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Indeterminate…3 |
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Don’t Know…(.D) |
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Refuse to Answer…(.R) |
|
|
|
If SEX12=yes and SEX12_F=1 or more |
|
Question: As far as you know, did she ever inject drugs like heroin, cocaine, or meth? |
|
Variable: LPIDU_F |
|
Response: last female partner ever injected |
|
No…0 |
|
Yes…1 |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
DRUG USE
Intro: Now I am going to ask you about experiences you may have had with drugs that you did NOT inject. This includes times that you have smoked, snorted, inhaled, or ingested drugs such as marijuana, methamphetamine, or cocaine. This also includes drugs such as Oxycontin or benzodiazepines that were not prescribed to you or that you used in a way other than instructed by your healthcare provider.” [Variable: intro_nidu] |
|
|
Question: Have you ever in your life used any drugs that you did not inject? |
|
Variable: EVRNIDU |
|
Response: Ever used non-injection drugs |
|
No…0 |
|
Yes…1 |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
|
|
|
If EVRNIDU=yes |
|
Question: When was the last time you used any drug that you did not inject? That is, how many days or months or years ago did you last use drugs? |
|
Variable: NIDUN |
|
Response: When last used non-injection drugs, number |
|
___ |
|
Range: 0-365 (if today, enter "0") |
|
Note: If Don’t Know or Refuse to Answer, leave it blank. |
|
|
|
If EVRNIDU=yes and NIDUN=0-365 |
|
Question: Was this in days or months or years? |
|
Variable: NIDUU |
|
Response: When last used non-injection drugs, unit |
|
Days…0 |
|
Months…1 |
|
Years…2 |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
|
|
|
If EVRNIDU=yes and NIDUN+NIDUU = last 12 months |
|
Question: In the past 12 months, which drugs did you use that you did NOT inject? Please say “yes” or “no” to each drug I mention. |
|
Variable: NIDUDRG |
|
Response: Non-injection drugs used |
|
NIDUDRGA: Marijuana |
|
NIDUDRGB: Methamphetamine |
|
NIDUDRGC: Crack cocaine |
|
NIDUDRGD: Powder cocaine |
|
NIDUDRGE: Downers, such as Benzodiazepines, Valium, Xanax, or Klonopin |
|
NIDUDRGF: Painkillers, such as Oxycontin, Dilaudid, or Percocet |
|
NIDUDRGG: X, ecstasy, or MDMA |
|
NIDUDRGH: Heroin |
|
NIDUDRGI: Fentanyl |
|
NIDUDRGJ: Stimulants, such as Adderall or Ritalin |
|
NIDUDRGK: Something else |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
|
|
Intro: Next I'm going to ask you about your injecting behaviors in the past 12 months, that is, since [fill with interview month] of last year. When I ask you about "needles," I'm talking about needles and syringes. (ASK ONLY IF IDU IN PAST 12 MONTHS) [intro_indr] |
|
|
If LINJN+LINJU= in last 12 months |
|
Question: In the past 12 months, did you use needles that someone else had already injected with? |
|
Variable: SHARNDLE |
|
Response: Used needle after, Y/N |
|
No…0 |
|
Yes…1 |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
HIV TESTING
Intro: Now I'm going to ask you a few questions about getting tested for HIV. Remember, an HIV test checks whether someone has HIV infection. [variable: intro_hiv] |
|
|
Question: Have you ever had an HIV test? |
|
Variable: EVERTEST |
|
Response: Ever tested for HIV |
|
No…0 |
|
Yes…1 |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
|
|
|
If EVERTEST=yes |
|
Question: Have you ever tested positive for HIV, that is, do you have HIV? |
|
Variable: EVERPOS |
|
Response: Ever test positive for HIV |
|
No…0 |
|
Yes…1 |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
|
|
|
If EVERPOS=yes |
|
Question: When did you FIRST test positive? Please tell me the month and year.
[INTERVIEWER: FIRST ENTER MONTH OF HIV TEST] |
|
Variable: POS1ST_mm |
|
January…1 |
|
February…2 |
|
March…3 |
|
April…4 |
|
May…5 |
|
June…6 |
|
July…7 |
|
August…8 |
|
September…9 |
|
October…10 |
|
November…11 |
|
December…12 |
|
Don’t Know…(0) |
|
Refuse to Answer…(-1) |
|
|
|
[INTERVIEWER: ENTER YEAR OF MOST RECENT HIV TEST] |
|
Variable: POS1ST_yy |
|
Response: Date of first positive test |
|
Response: __ __ __ __ (YYYY) |
|
Range (year)…1900-2100 |
|
Note: If Don’t Know or Refuse to Answer, enter 1900. |
|
|
|
If EVERTEST=yes and EVERPOS=no/DK/Refused |
|
Question: Were you tested for HIV in the past 12 months, that is, since [fill with interview month] of last year? |
|
Variable: RCNTST12 |
|
Response: HIV test in the past 12 months |
|
No…0 |
|
Yes…1 |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
SEXUALLY TRANSMITTED DISEASES
Intro: Now, I'm going to ask you some questions about sexually transmitted diseases, or STDs, other than HIV and hepatitis. [variable: intro_std] |
|
|
Question: In the past 12 months, that is, since [fill with interview month] of last year, were you tested by a doctor or other health care provider for a sexually transmitted disease like gonorrhea, chlamydia, or syphilis? Do NOT include tests for HIV or hepatitis. |
|
Variable: STDTEST |
|
Response: Tested for STD past 12 months |
|
No…0 |
|
Yes…1 |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
|
|
|
If SEX12_M=yes, and GEND=male and STDTEST=yes |
|
Question: In the past 12 months, did you have an anal or rectal STD test? |
|
Variable: RSTDTEST |
|
Response: Rectal STD test past 12 months |
|
No…0 |
|
Yes…1 |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
|
|
Intro: In the past 12 months, has a doctor or other health care provider told you that you had… [variable: std_group] |
|
|
Question: Gonorrhea? |
|
Variable: GONORR |
|
Response: Gonorrhea past 12 months |
|
No…0 |
|
Yes…1 |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
|
|
|
Question: Chlamydia? |
|
Variable: CHLAMYD |
|
Response: Chlamydia past 12 months |
|
No…0 |
|
Yes…1 |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
|
|
|
Question: Syphilis? |
|
Variable: SYPHILIS |
|
Response: Syphilis past 12 months |
|
No…0 |
|
Yes…1 |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
HIV PREVENTION
Intro: Next I'd like to ask you about HIV prevention activities that happen around here. [variable: intro_hivpre] |
|
|
Question: In the past 12 months, that is, since [fill with interview month] of last year, have you gotten any free condoms, not counting those given to you by a friend, relative or sex partner? |
|
Variable: COND12 |
|
Response: Received free condoms past 12m |
|
No…0 |
|
Yes…1 |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
|
|
|
If LINJU= in last 12 months |
|
Question: In the past 12 months, have you used services at a syringe exchange program? |
|
Variable: SSPU |
|
Response: SSP use, 12m |
|
No…0 |
|
Yes…1 |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
|
|
|
If EVERPOS NE yes and (no previous HIV-positive test result) |
|
Intro: The next questions are about the use of anti-HIV medicines, also called antiretrovirals. There are two ways that people who are HIV-negative can take anti-HIV medicines to reduce their risk of becoming infected. [variable: intro_pepre] |
|
Question: PRE-exposure prophylaxis, or PrEP, is an antiretroviral medicine, such as Truvada (or Descovy), taken for months or years by a person who is HIV-negative to reduce the risk of getting HIV. Before today, have you ever heard of PrEP? |
|
Variable: PRPAWR |
|
Response: PrEP, awareness |
|
No…0 |
|
Yes…1 |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
|
|
|
If PRPAWR=Yes |
|
Question: In the past 12 months, have you had a discussion with a health care provider about taking PrEP? |
|
Variable: PRPDSC |
|
Response: PrEP, discussed with HCP, 12m |
|
No…0 |
|
Yes…1 |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
|
|
|
If PRPAWR=Yes |
|
Question: In the past 12 months, have you taken PrEP to reduce the risk of getting HIV? |
|
Variable: PRPUS12M |
|
Response: PrEP use, 12m |
|
No…0 |
|
Yes…1 |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
|
If EVERPOS NE yes and (no previous HIV-positive test result) |
|
Question: When a person who is HIV-negative takes pills for 28 days after a single high-risk exposure to reduce their chances of getting HIV, this is called POST-exposure prophylaxis, or PEP. In the past 12 months, have you taken PEP? |
|
Variable: PEPUSE |
|
Response: PEP, use, 12m |
|
No…0 |
|
Yes…1 |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
SELF-REPORTED POSITIVE (SRP) HIV CARE
If EVERPOS = yes |
|
|
|
Intro: Next I'd like to ask you a few questions about care you may have received for your HIV infection. [Variable: intro_SRP] |
|
|
Question: Have you ever been seen by a doctor, nurse, or other health care provider for a medical evaluation or care related to your HIV infection? |
|
Variable: POSMD |
|
Response: Seen health care provider for HIV infection |
|
No…0 |
|
Yes…1 |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
|
|
|
If POSMD=Yes |
|
Question: When did you first go to your health care provider after learning you had HIV? Please tell me the month and year.
[INTERVIEWER: FIRST ENTER MONTH] |
|
Variable: FRSMD_mm |
|
January…1 |
|
February…2 |
|
March…3 |
|
April…4 |
|
May…5 |
|
June…6 |
|
July…7 |
|
August…8 |
|
September…9 |
|
October…10 |
|
November…11 |
|
December…12 |
|
Don’t Know…(13) |
|
Refuse to Answer…(14) |
|
|
|
[INTERVIEWER: ENTER YEAR] |
|
Variable: FRSMD_yy |
|
Response: First saw health care provider after learning HIV+ |
|
Response: __ __ __ __ (YYYY) |
|
Range (year)…1900-2100 |
|
Note: If Don’t Know or Refuse to Answer, enter 2100. |
|
|
|
Question: Are you currently taking antiretroviral medicines to treat your HIV infection? |
|
Variable: CURRAMED |
|
Response: Currently taking antiretrovirals |
|
No…0 |
|
Yes…1 |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
|
|
Intro: An HIV viral load test measures the amount of HIV in your blood. [Variable: intro_vl] |
|
|
Question: In the past 12 months, that is, since [fill with interview month] of last year, have you had an HIV viral load test? |
|
Variable: VLTST12 |
|
Response: viral load test in past 12 months |
|
No…0 |
|
Yes…1 |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
|
|
|
If VLTST12=Yes |
|
Question: A person with HIV whose amount of virus in their body is very low may be told by a health care provider that their HIV viral load is undetectable. Thinking of your most recent viral load test, was the result undetectable, detectable, or you don’t know? |
|
Variable: VLTSTRSLT |
|
Response: result of most recent viral load test |
|
Undetectable…1 |
|
Detectable…2 |
|
Don’t Know…(.D) |
|
Refuse to Answer…(.R) |
|
|
END OF SURVEY
|
If CONSENTB = no |
|
Question: My records reflect that you did not agree to HIV testing when asked earlier during the interview. Before I close out the survey, I’d like to ask you again about whether or not you would like an HIV test. Did you want the HIV test that is part of today’s survey? [Do NOT read choices] |
|
Variable: C_T_CNST |
|
Response: Confirmation of HIV testing consent |
|
No, respondent does NOT want an HIV test…0 |
|
Yes, respondent DOES want an HIV test…1 |
|
|
|
If C_T_CNST = Yes |
|
Question: Do you agree to HIV counseling and testing? |
|
Variable: HIVCNSTB |
|
Response: Revised consent to HIV testing |
|
No…0 |
|
Yes…1 |
|
|
|
If HIVCNSTB = Yes |
|
Question: Do you agree to let us store some of your test sample(s) for future testing? |
|
Variable: CNSTSTOREB |
|
Response: Revised consent to specimen storage |
|
No…0 |
|
Yes…1 |
|
|
|
[INTERVIEWER: Enter the end time] |
|
Variable: ENDTIME |
FLASHCARD A
MONTHLY Income |
OR |
YEARLY Income |
|
||
A. |
$0 to $416 |
or |
A. |
$0 to $4,999 |
|
B. |
$417 to $833 |
or |
B. |
$5,000 to $9,999 |
|
C. |
$834 to $1,041 |
or |
C. |
$10,000 to $12,499 |
|
D. |
$1,042 to $1,249 |
or |
D. |
$12,500 to $14,999 |
|
E. |
$1,250 to $1,666 |
or |
E. |
$15,000 to $19,999 |
|
F. |
$1,667 to $2,083 |
or |
F. |
$20,000 to $24,999 |
|
G. |
$2,084 to $2,499 |
or |
G. |
$25,000 to $29,999 |
|
H. |
$2,500 to $2,916 |
or |
H. |
$30,000 to $34,999 |
|
I. |
$2,917 to $3,333 |
or |
I. |
$35,000 to $39,999 |
|
J. |
$3,334 to $4,166 |
or |
J. |
$40,000 to $49,999 |
|
K. |
$4,167 to $4,999 |
or |
K. |
$50,000 to $59,999 |
|
L. |
$5,000 to $6,249 |
or |
L. |
$60,000 to $74,999 |
|
M. |
$6,250 to $8332 |
or |
M. |
$75,000 to $99,999 |
|
N. |
$8333 or more |
or |
N. |
$100,000 or more |
|
FLASHCARD B
A private health plan- purchased through an employer or purchased directly
Medicaid- for people with low incomes
Medicare- for the elderly and people with disabilities
Indian Health Service
TRICARE/CHAMPUS
Veterans Administration coverage
Some other government plan
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Cha, Susan (CDC/DDID/NCHHSTP/DHPSE) |
| File Modified | 0000-00-00 |
| File Created | 2022-10-03 |