AA STD DIsparities - Participant Domain Assessment

African American STD Disparities Health Communication Project

#0920-0798

Attachment 5

Participant Domain Assessment Structured Data Collection

(Phase 1 Only)

Form Approved

OMB No. 0920-0798

Expiration Date: 01/31/2011

Participant Domain Assessment Structured Data Collection

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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0798).

Pile Sort of STDs:

1. What I would like you to do is read through the set of cards, each contains the name of an STD, and then sort them into piles so that like or similar ones are in the same piles. I am going to ask that you use at least two piles and no more than seven.

[After sorting is complete]

2. Can you tell me about each of the piles you have created? What names would you give each of them?

List of STDs to sort:

Bacterial Vaginosis	Sometimes also referred to as,	BV
Chancroid
Chlamydia	Sometimes also referred to as	The Clam
Genital herpes
Gonorrhea	Sometimes also referred to as	Dose, Clap, Drip
Hepatitis B	Sometimes also referred to as	Hep B
HIV	Sometimes also referred to as	Has the Package, HI-v
Human Papillomavirus	Sometimes also referred to as	HPV
Pubic lice	Sometimes also referred to as	Crabs
Syphilis	Sometimes also referred to as	Syph, Pox, Bad Blood
Trichomoniasis	Sometimes also referred to as	Trich
Genital Warts

Form Approved

OMB No. 0920-0798

Expiration Date: 01/31/2011

Participant Domain Assessment Structured Data Collection

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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0798).

Rating of STD Attributes:

Please indicate on the following seven point scale how serious you consider each of the following STDs to be. If you haven’t heard of the STD or don’t know enough about it to answer the question, check “don’t know.”

STDs = Sexually Transmitted Disease	Not Serious 1	Somewhat serious 2	Very Serious 3	Don’t know 4
Bacterial Vaginosis (BV)
Chancroid
Chlamydia (The Clam)
Genital herpes
Gonorrhea (Dose, Clap, Drip)
Hepatitis B (Hep B)
HIV (Has the Package, HI-v)
Human Papillomavirus (HPV)
Pubic lice (Crabs)
Syphilis (Syph, Pox, Bad Blood)
Trichomoniasis (Trich)
Genital Warts

Please indicate on the following seven point scale how curable you consider each of the following STDs. If you haven’t heard of the STD or don’t know enough about it to answer the question, check “don’t know.”

STDs = Sexually Transmitted Disease	Notcurable 1	Somewhat curable 2	Easily curable 3	Don’t know 4
Bacterial Vaginosis (BV)
Chancroid
Chlamydia (The Clam)
Genital herpes
Gonorrhea (Dose, Clap, Drip)
Hepatitis B (Hep B)
HIV (Has the Package, HI-v)
Human Papillomavirus (HPV)
Pubic lice (Crabs)
Syphilis (Syph, Pox, Bad Blood)
Trichomoniasis (Trich)
Genital Warts

Please indicate on the following seven point scale how at risk you consider yourself to be for each of the following STDs. If you haven’t heard of the STD or don’t know enough about it to answer the question, check “don’t know.”

STDs = Sexually Transmitted Disease	Not at all at risk 1	Somewhat at risk 2	Very much at risk 3	Don’t know 4
Bacterial Vaginosis (BV)
Chancroid
Chlamydia (The Clam)
Genital herpes
Gonorrhea (Dose, Clap, Drip)
Hepatitis B (Hep B)
HIV (Has the Package, HI-v)
Human Papillomavirus (HPV)
Pubic lice (Crabs)
Syphilis (Syph, Pox, Bad Blood)
Trichomoniasis (Trich)
Genital Warts

Please indicate on the following seven point scale how shameful people consider each of the following STDs to be for those infected. If you haven’t heard of the STD or don’t know enough about it to answer the question, check “don’t know.”

STDs = Sexually Transmitted Disease	Not at all at risk 1	Somewhat at risk 2	Very much at risk 3	Don’t know 4
Bacterial Vaginosis (BV)
Chancroid
Chlamydia (The Clam)
Genital herpes
Gonorrhea (Dose, Clap, Drip)
Hepatitis B (Hep B)
HIV (Has the Package, HI-v)
Human Papillomavirus (HPV)
Pubic lice (Crabs)
Syphilis (Syph, Pox, Bad Blood)
Trichomoniasis (Trich)
Genital Warts