0920- Client Survey

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Evaluation of safe spaces in CDC-directly funded community-based organizations

Attachment 4

Client Survey

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-New)

☐afe Space Use
Why did you come to [safe space name] for your most recent visit? Select all that apply ☐ To have fun ☐ To meet people ☐ For HIV testing ☐ For HIV medical care ☐ For PrEP services ☐ For other HIV services (Briefly describe) ­­­­­­­­­­­­­­­­­­­­­­_________________ ☐ For other support services (e.g., education, employment, housing) ☐ For a specific event (e.g., movie night) ☐ Nowhere else to go ☐ Other (Briefly describe) ______________ ☐ Decline to answer At your most recent visit to the safe space, did you get what you came for? Yes No I got some but not everything I came for Decline to answer How many times have you visited [safe space name] in the past 12 months? ___________ How many times have you visited [safe space name] in the past 30 days? ___________
Perceptions about Safe Space
Overall, how satisfied are you with [safe space name]? Very satisfied Satisfied Neutral Dissatisfied Very dissatisfied Decline to answer Do you plan to return to [safe space name] again? Definitely Probably Probably not Definitely not Decline to answer Did [safe space name] provide you with the following HIV services at any time you visited: Yes No I don’t need any Decline to answer help with this HIV education HIV testing Linkage to HIV medical care Referral to PrEP services Other HIV services (briefly describe): ________________ Do you feel that [safe space name] has helped you at any time with: Yes No I don’t need any Decline to answer help with this Transportation Housing Health insurance Non-HIV related healthcare Hormone replacement therapy Job opportunities Educational opportunities Do you feel that [safe space name] helped at any time with hardships in your life, such as: Yes No I don’t need any Decline to answer help with this HIV stigma Homophobia/transphobia Racism Financial hardship Substance abuse Mental health concerns
Is the environment at [safe space name]… Yes No Decline to answer Welcoming Made with me in mind Meant for people my age Visited by LGBT persons of color Affirming to me Using language that I can relate to Staffed with people that are like me A nice physical space Easy to get to Open when I wanted to visit it? Did [safe space name]… Yes No Decline to answer Make me feel respected Make me feel safe Make me feel connected to others like me
How old are you? __________ In which state do you live? ____________ What is your zip code? ___________ Are you Hispanic or Latino? Yes No I don’t know Decline to answer Which race(s) are you? Select all that apply ☐ Asian ☐ American Indian or Alaska Native ☐ White ☐ Black or African American ☐ Native Hawaiian or Other Pacific Islander ☐ Don’t Know ☐ Decline to answer What sex were you assigned at birth, on your original birth certificate? Male Female Decline to answer How do you identify yourself? Male Female Transgender man/trans man Transgender woman/trans woman Nonbinary A gender not listed here: _____________ Decline to answer In the past five years, have you: ☐Had sex with a man ☐Had sex with a woman ☐ Had sex with a transgender person ☐ Decline to answer	What is the highest level of education that you completed? No schooling completed Less than high school Some high school High school graduate/GED Some college Technical or trade school Bachelor’s degree Master’s degree Doctoral-level degree Decline to answer What is your current work situation? Employed full-time Employed part-time Not employed at this time Decline to answer Are you currently a student? Yes No Decline to answer What is your living situation today? I have housing I do not have permanent housing (couch surfing, in a hotel) I am experiencing homelessness (in a shelter, living outside on the street, in a car, or in a park) Decline to answer
HIV-related Questions
What was the result of your last HIV test? Positive Negative Don’t know Never been tested for HIV Decline to answer Are you currently receiving care for HIV? (Only for people with HIV) Yes No Decline to answer Are you currently taking PrEP? (Only for people who test negative for HIV) Yes No Don’t know what PrEP is Decline to answer In the past 3 months, have you… Yes No Decline to answer Had anal or vaginal sex without a condom? Injected drugs? Been diagnosed with a sexually transmitted infection? Which of these services did you receive from [agency name] in the past 30 days? Select all that apply ☐ HIV testing ☐ STI testing ☐ Linkage to HIV medical care (e.g., ARTAS, STEPS to Care) ☐ PrEP services ☐ Medication adherence support ☐ Referrals to other services (Briefly describe)