African American STD Disparities Health Communication Project
ATTACHMENT 3
Web-based Survey Screener
Form Approved
OMB No. 0920-0572
Expiration Date: 2/28/2015
1. Are you of Hispanic or Latino origin?
1 Yes [INELIGIBLE]
2 No
2. Which of the following best describes your race? (Check all that apply)
1 White [INELIGIBLE]
2 Black or African American
3 Asian [INELIGIBLE]
4 Native Hawaiian or Other Pacific Islander [INELIGIBLE]
5 American Indian or Alaska Native [INELIGIBLE]
3. How old are you?
Age__________ [TERMINATE IF UNDER 18 OR OVER 30 AND GO TO CLOSING]
1 Don’t know [TERMINATE AND GO TO CLOSING]
9 Refuse to answer [TERMINATE AND GO TO CLOSING]
Public reporting burden of this collection of information is estimated to average 2 minutes per response, including time for reviewing instructions, searching for 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 (0920-0572).
4. Gender
1 Male [Quota is 500]
2 Female [Quota is 50]
9 Refuse to answer
5. Would you describe yourself as:
1 Heterosexual or straight
2 Homosexual or “gay” or same gender loving
3 Bisexual or two spirited
4 Other, specify
9 Refuse to answer [Terminate]
[FOR Q 4 & 5: TARGET IS 450 HETEROSEXUAL MEN, 50 HETEROSEXUAL WOMEN, 50 GAY/BI MEN]
6. What is the highest level of education you have completed?
1 Grade school
2 Less than high school graduate/some high school
3 High school graduate of completed GED
4 Some college or technical school
5 Received four-year college degree
6 Some post graduate studies
7 Received advanced degree
8 Other____________________
9 Refuse to answer
[ATTEMPT MIX]
Next, we’d like to ask you some personal questions about your relationships and sex partners. Sex partner refers to any person you have sex with. It could be a husband, wife, boyfriend, girlfriend, or a casual partner.
7. What is your current relationship status? Are you…?
1 Single
2 Married to a man
3 Married to a woman
4 In a relationship with a man
5 In a relationship with a woman
6 Divorced or Widowed
9 Refuse to answer
[TARGET 75% NOT MARRIED]
8. Within the past 6 months, who have you primarily had sex with?
1 A male
2 A female
3 Haven’t had sex in the last 6 months [TERMINATE]
9 Refused [TERMINATE]
[USE IN CONJUNCTION WITH Q 4 & 5 FOR TARGETS AROUND HETEROSEXUAL AND NON-HETEROSEXUAL PARTICIPANTS]
9. Do you currently have a main sex partner—that is, a partner you would call your boyfriend, girlfriend, spouse, significant other, or life partner?
1 Yes
2 No
9 Refuse to answer
10. Is your main partner male, female, or transgender?
1 Male
2 Female
3 Transgender
9 Refuse to answer
11. Do you have sex only with the person with whom you are in a committed relationship?
1 Yes
2 No
9 Refuse to answer
[USE Q 9, 10, 11 TO MEET TARGETS FOR INDIVIDUALS AT MORE RISK FOR ACQUIRING OR TRANSMITTING STDS. TARGET MAJORITY TO BE THOSE WITHOUT A MAIN SEX PARTNER OR THOSE WHO REPORT SEX OUTSIDE COMMITTED RELATIONSHIP]
Thank you for answering these questions. This survey is part of a research study on behalf of the Centers for Disease Control and Prevention (CDC) regarding sexual health and we would like to hear your views. The survey should take no longer than 30 minutes to complete. As a token of appreciation, you will receive points that can be redeemed online through a variety of participating retailers. This is an important research effort and we appreciate your assistance.
Thank you for answering all of the questions. You are not eligible to be in this study because you did not meet our eligibility criteria. We value your interest in this research study. Thank you for being willing to help us.
| File Type | application/msword |
| Author | lgilbert |
| Last Modified By | CDC User |
| File Modified | 2013-04-03 |
| File Created | 2013-04-03 |