OMB
No. XXXX-XXXX
Expires XX/XX/20XX
ATTACHMENT C
KEY INFLUENCER SURVEY INSTRUMENT
National Survey on Knowledge, Attitudes, and Behaviors
Related to HIV Vaccine Research
We need your assistance to improve our understanding of attitudes related to HIV vaccine research. In appreciation for your assistance, a gift code worth $25 at Amazon.com will be provided to you at the end of this survey.
More than 1,000,000 Americans are thought to be infected with Human Immunodeficiency Virus (HIV), the virus that causes Acquired Immune Deficiency Syndrome (AIDS). The National Institute of Allergy and Infectious Disease (NIAID) at the National Institutes of Health (NIH) is working with researchers to develop a vaccine that prevents HIV infection. Survey data will guide efforts to educate the public about clinical trials, which are a necessary part of the development of an effective vaccine.
You have been selected for participation in this survey because of your affiliation with [ORG NAME], which serves communities that are highly impacted by HIV/AIDS.
Your personal information will be protected to the fullest extent permitted by law. Your answers will be stored separate from your identifying information in a secure environment. During analysis, survey answers will be combined across all respondents and reported in the aggregate. NIAID, the NIAID HIV Vaccine Research Education Initiative and your employer will not be informed of your personal responses to survey questions.
Your participation in this survey is voluntary. Though there are no penalties for not responding to the survey, if you do not respond, the survey finding may not represent your point of view and the final results may be inaccurate.
In about a year we will ask you to fill out a similar survey in order to assess your attitudes at that time.
If you have any questions about the survey, please contact Dan Eckstein:
DEckstein@novaresearch.com
NOVA Research Company
4600 East-West Highway, Suite 700
Bethesda, MD
(301) 986-1891
Public reporting burden for this collection of information is estimated to average 20 minutes per response. This time includes the length of time allotted for the survey questions. 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN; PRA (0925-0585). Do not return the completed form to this address.
What is your current position with respect to [qualifying organization]?
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Board Member |
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Executive Officer |
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Program Manager/Project Director |
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Outreach Worker/Field Worker |
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Other (specify): |
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How long have you been associated with this organization?
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More than 1 year |
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Less than 1 year |
Now we are going to ask you some questions related to HIV/AIDS.
Awareness
How recently have you heard or read about research efforts to develop a vaccine that prevents HIV infection? HIV is the virus that causes AIDS.
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Less than 1 year ago |
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1 year or more ago |
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I heard about it but I don’t know when |
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Not sure if I ever heard about it |
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Never heard of it |
SKIP to 4 |
From which sources have you read of or heard about research efforts to develop a vaccine that prevents HIV? (Check all that apply).
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ii. Radio |
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iii. Newspaper or Magazine |
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iv. Internet: |
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Wiki |
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Nonprofit Web site |
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Government Web site |
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Social Networking Web site (e.g., Facebook, Twitter) |
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Blog |
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v. Non-work-related interpersonal contact (discussion, email) |
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vi. E-mail listserv |
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vii. Work-related duties (e.g., presentations, healthcare outreach, community work) or interests promoted at work |
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viii. Workshop, health fair, brochure, program, or any other activity sponsored by an agency in your community |
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ix. Presentation at professional conference/meeting |
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x. Other (specify): |
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xi. Don’t know |
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Have you seen “Be The Generation” materials or “Be The Generation” Web Site?
(Check all that apply).
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Yes |
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No |
SKIP TO 5 |
Did you hear of “Be The Generation” through your work? (Check all that apply).
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No, I didn’t hear of “Be The Generation” through my work |
SKIP to 5 |
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Yes, I’ve heard of “Be The Generation” through my work, but I have not used these materials |
SKIP to 5 |
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Yes, I use these materials in my work now |
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Yes, I’ve used these materials in the past |
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Other (specify): |
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How has your organization used “Be The Generation” materials?
(Check all that apply).
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Attitudes
How relevant is the topic of HIV vaccine research to you, your friends and family, and the community served by [qualifying organization]?
(Check one response in each row).
How relevant is HIV vaccine research to…
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Not Relevant At All |
Slightly Relevant |
Somewhat Relevant
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Very Relevant |
Extremely Relevant |
Don’t Know |
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How much do you agree or disagree with each of the following statements?
(Check one response in each row).
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Strongly Disagree |
Some-what Disagree |
Don’t Know/ Neither Agree Nor Disagree |
Agree |
Strongly Agree |
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How open are the people around you to supporting HIV vaccine research? How open are… (Check one response in each row).
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Not at All Open |
Not Very Open |
Somewhat Open
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Very Open |
Extremely Open |
Don’t Know |
a. Your family? |
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b. Your friends? |
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c. Co-workers? |
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d. The community served by [qualifying organization]? |
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How important is it to you to increase support for HIV vaccine research?
(Check one response in each row).
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Not at All Important |
Not Very Important |
Somewhat Important |
Very Important |
Extremely Important |
Don’t Know |
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IF you checked “Not at All” or Not Very” Important, SKIP to Question 9.
a. How confident are you that you are able to increase support for HIV vaccine research among… ?
(Check one response in each row).
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Not at All Confident |
Not Very Confident |
Somewhat Confident
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Very Confident |
Extremely Confident |
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ii. Your friends? |
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iii. Your co-workers? |
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iv. The community served by [qualifying organization]? |
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How much do you agree or disagree with the following statements?
(Check one response in each row).
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Strongly Disagree |
Somewhat Disagree |
Don’t Know/ Neither Agree Nor Disagree |
Somewhat Agree |
Strongly Agree |
a. I have the skills needed to spread the word about the importance of HIV vaccine research. |
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b. I have the knowledge needed to spread the word about the importance of HIV vaccine research. |
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c. I have the resources and materials to spread the work about the importance of HIV vaccine research. |
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d. I have the opportunity to speak out about the importance of HIV vaccine research. |
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How willing would you be to…
(Check one response in each row).
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Not at All Willing |
Not Very Willing |
Somewhat Willing
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Very Willing |
Extremely Willing |
Don’t Know |
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Activities Supportive of HIV Vaccine Research
Have top administrators of [qualifying organization] requested or received a briefing regarding the status of HIV vaccine research?
(Check one response).
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Yes |
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No |
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Don’t Know |
Have you personally provided information on HIV vaccine research to top administrators of [qualifying organization]?
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Yes |
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No |
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Don’t Know |
Have the staff of [qualifying organization] received in-service training related to HIV vaccine research?
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Yes, on site |
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Yes, off site |
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No |
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Don’t Know |
Has [qualifying organization] raised awareness of HIV vaccine research as an important strategy for controlling the AIDS epidemic? (Check one response).
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Yes How (specify): |
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No |
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Don’t Know |
Does [qualifying organization] provide information about HIV Vaccine Research through…
(Check one response in each row).
Type of Media |
Yes |
No |
Don’t Know |
a. The Internet? |
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b. Hard copy materials? |
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c. Presentations/ conferences/health fairs? |
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d. Mass media news releases? |
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e. Church communities? |
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f. Community events/festivals? |
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g. Universities and colleges? |
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h. Word of mouth? |
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Have you personally provided information to others about HIV vaccine research through…
(Check one response in each row).
Type of Media |
Yes |
No |
Don’t Know |
a. Distributing materials? |
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b. Writing articles or papers? |
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c. Making presentations |
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d. Providing interviews? |
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Have you personally championed support for HIV vaccine research within your organization? (Check one response).
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Yes, more than one year ago |
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Yes, within the last year |
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No |
Have you personally taken a course or attended a workshop providing training on how to improve support for HIV vaccine research? (Check one response).
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Yes, more than one year ago |
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Yes, within the last year |
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No |
In the last three months, about how many times have you engaged in the following activities? (Check one response in each row).
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Not at All |
Once or Twice |
3 – 5 Times
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6 – 8 Times |
9 or More Times |
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In the past year, have you worked with or obtained information from any of the following organizations? (Check all that apply in each row).
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Obtained Info |
Worked With |
Other Contact |
No Contact |
Don’t Know |
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Demographics
What is your age? (Check only one).
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Under 21 years |
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21-30 years |
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31-40 years |
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41-50 years |
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51-60 years |
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61-70 years |
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over 70 years |
What is your gender?
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Male |
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Female |
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Transgender |
What is your ethnicity? (Check only one).
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Hispanic or Latino |
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not Hispanic or Latino |
What is your race? (Check all that apply).
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American Indian or Alaska Native |
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Asian |
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Black or African American |
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Native Hawaiian or Other Pacific Islander |
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White |
Which of the following categories best describes the highest educational level you attained? (Check only one).
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Less than a high school degree |
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High school degree or GED |
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Some college/technical school/associates degree |
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College degree |
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Some graduate school or more |
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Other (specify): |
In the United States, African Americans, Hispanics/Latinos, and men who have sex with men (MSM) are populations that have been disproportionately affected by HIV/AIDS. For this reason, NIAID is particularly interested in learning about communities with these characteristics.
Thinking about your social network (your clients, coworkers, friends and family), about how many are members of the following populations?
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None |
Some |
Many |
Most |
Don’t Know |
People Served by [qualifying organization] |
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African American |
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Hispanic/Latino |
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MSM |
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Coworkers |
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African American |
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Hispanic/Latino |
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MSM |
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Family |
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African American |
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Hispanic/Latino |
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MSM |
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Friends |
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African American |
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Hispanic/Latino |
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MSM |
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Please add any other comments regarding HIV vaccine research of which you believe NIAID should be aware:
We would like to gather information from other staff from [organization] who have direct contact with the constituents of [organization]. Would you be willing to provide us with the names of two people whom we could contact for participation in this survey?
Name Position Email Telephone
THANK YOU FOR YOUR ASSISTANCE
TO OBTAIN YOUR $25 HONORARIUM, CLICK ON THE LINK BELOW TO GO TO AMAZON.COM.
File Type | application/msword |
File Title | Table 1 |
File Modified | 2010-01-20 |
File Created | 2010-01-20 |