MSM_OMB_Attach_2_Web-based_Screener_and_Q_8Jan2013_clean_V_4_0

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is xxxx-xxxx. The time required to complete this information collection is estimated to average 24 minutes per response, including the time to review instructions, search existing data sources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA(XXXX-XXXX). Do not return the completed form to this address.

OMB Number: XXXX-XXX

OMB Expiration Date: XX/XX/XXX

Attachment 2 – Web-based Screener and Questionnaire

OMB Number: TBD

Blood Donation Rules Opinion Study (Blood DROPS)Draft Content for Web-based Survey

Once final survey content and study information have been agreed to, study investigators will provided exact versions of all web survey materials to OMB; further, we recognize that clearance will not be obtained until after OMB has received, reviewed, and approved these documents."

Blood Donation Rules Opinion Study (Blood DROPS)

ELIGIBILITY

The survey will begin by asking a number of questions to determine if you qualify to participate in the study.

You may complete only one survey. In addition, only a single member of a household is eligible to take the survey. Additional criteria are explained later in the survey's consent document.

If you are accessing this survey using an "anonymous web proxy" that masks your true IP address, or any other method that alters information about your Internet connection, then you are ineligible to participate in this study.

INSTRUCTIONS FOR COMPLETING THE SURVEY

If you want to return to a previous page of the survey, click the "Previous Page" button located at the bottom of the survey web page. Do not use the "Back" button in the toolbar of your web browser.

You may exit the survey at any time and then return later to complete the survey, but only by clicking on the box titled "Click here to save your progress and continue the survey later," which appears at the bottom of every survey page. When you return to the survey web site, the questions will begin exactly where you left off. We ask that you please complete the survey within three days of beginning it.

SURVEY QUESTIONS AND RESPONSE OPTIONS

1) Where did you hear about this study? Please be as specific as possible by telling us the name of an organization, establishment, or location of a study flyer, the name of a web site, or the type of person who referred you (such as a recruiter, or friend, or co-worker), etc.

2) What sex were you assigned at birth?

( ) Male

( ) Female

3) What is your age?

( ) under 18

( ) 18-24

( ) 25-34

( ) 35-54

( ) 55+

4) Are you of Hispanic/Latino/Spanish origin?

( ) No

( ) Yes

5) How would you describe your race? (If multi-racial, check all that apply.)

[ ] White/Caucasian

[ ] Black/African American

[ ] Asian

[ ] American Indian/Alaska Native

[ ] Native Hawaiian or Other Pacific Islander

6) In what country do you live?

( ) United States of America

( ) Other

7) In what state do you live?

Pick list of US States provided.

8) What are the first three digits of your zip code? If you currently are living in temporary housing such as a student dorm or friend's place, please use the zip code of your current address rather than a permanent address. ___ ______

9) In what city do you live?____________________________________________

MSM Survey Respondents Only

10) Since 1977, have you had any kind of sexual contact with another male, even if only once? Sexual contact is any kind of contact with another person that you felt was sexual - it could be just kissing or touching, or intercourse, or any other form of sex.

( ) Yes

( ) No

MSM Survey Respondents Only

11) Have you ever been tested for or been told that you have any of the following infections?

	Never Tested	Tested Positive	Tested Negative
Hepatitis B Virus (HBV)	( )	( )	( )
Hepatitis C Virus (HCV)	( )	( )	( )
Human Immunodeficiency Virus (HIV)	( )	( )	( )

MSM and Blood Donor Surveys: IF: Zip code is not: 060 061 062 063 064 065 066 067 068 069 160 161 162 164 166 168 150 151 152 153 154 155 156 157 158 159 444 439 260 263 265 267 530 531 535 539 541 542 543 544 545 546 549 940 941 944 945 946 949 950 954 956 959 960 961 OR The answer to Question #2 is Female OR The answer to Question #3 is under 18 OR The answer to Question #5 is Other OR The answer to Question #9 is No OR Any answer to Question #10 is Tested Positive THEN: Disqualify and display:

Sorry, you do not qualify to take this survey.

Male Blood Donor Survey: Same logic as MSM Survey, except that No on Question #9 does not disqualify them from continuing with the survey.

Consent

Congratulations! Based on your answers, you are eligible to take our survey.

IF: The answer to Question #11 is I do not wish to participate in this study

THEN: Disqualify and display:

Thank you for time. Since you do not consent to participate, you are not eligible to continue.

12) In what year were you born?

19____

IF: The answer to Question #12 is greater than 95

THEN: Ineligible and display:

Sorry, you do not qualify to take this survey.

For the next few questions the term "sex" refers to any of the following activities, with or without ejaculation, whether or not a condom or other protection was used, and no matter how brief its duration.

Vaginal sex: contact between penis and vagina
Oral sex: mouth or tongue on someone's vagina, penis, or anus
Anal sex: contact between penis and anus

13) Have you ever (in your life time) had vaginal, oral, or anal sex with a woman?

( ) Yes

( ) No, I have never had vaginal, oral, or anal sex with a woman

IF: The answer to Question #13 is No, I have never had vaginal, oral, or anal sex with a woman THEN: Jump to Question #17

14) When did you last have vaginal, oral, or anal sex with a woman?

( ) During the last month

( ) 1 – 5 months ago

( ) 6 – 12 months ago

( ) 1 – 2 years ago

( ) 2 – 5 years ago

( ) 5 – 35 years ago

( ) More than 35 years ago (before 1977)

( ) Don't know or don't remember

15) How many women have you had vaginal, oral, or anal sex with in the last 5 years?

( ) I have not had vaginal, oral, or anal sex with a woman in the last 5 years

( ) 1

( ) 2 – 5

( ) 6 – 10

( ) More than 10

( ) Don’t know or don’t remember how many

IF: The answer to Question #15 is I have not had vaginal, oral, or anal sex with a woman in the last 5 years THEN: Jump to Question #17

16) How many women have you had vaginal, oral, or anal sex with in the last year?

( ) I have not had vaginal, oral, or anal sex with a woman in the last year

( ) 1

( ) 2 – 5

( ) 6 – 10

( ) More than 10

( ) Don’t know or don’t remember how many

17) Have you ever (in your life time) had oral or anal sex with another man?

( ) Yes

( ) No, I have never had oral or anal sex with another man

IF: The answer to Question #17 is exactly equal to No, I have never had oral or anal sex with another man THEN: Jump to Question #21.

18) When did you last have oral or anal sex with another man?

( ) During the last month

( ) 1 – 5 months ago

( ) 6 – 12 months ago

( ) 1 – 2 years ago

( ) 2 – 5 years ago

( ) 5 – 35 years ago

( ) More than 35 years ago (before 1977)

( ) Don't know or don't remember

19) How many men have you had oral or anal sex with in the last 5 years?

( ) I have not had oral or anal sex with any other man in the last 5 years

( ) 1

( ) 2 – 5

( ) 6 – 10

( ) More than 10

( ) Don’t know or don’t remember how many

IF: The answer to Question #19 is exactly equal to I have not had oral or anal sex with another man in the last 5 years THEN: Jump to Question #21.

20) How many men have you had oral or anal sex with in the last year?

( ) I have not had oral or anal sex with any other man in the last year

( ) 1

( ) 2 – 5

( ) 6 – 10

( ) More than 10

( ) Don’t know or don’t remember how many

21) Are you currently married to or in a long-term relationship with a woman?

( ) Yes

( ) No

IF: The answer to Question #21 is No THEN: Jump to Question #24

IF: The answer to Question #17 is No, I have never had oral or anal sex with another man THEN: Jump to Question #27

22) During the time you have been in this relationship, have you had oral or anal sex with another man?

( ) Yes

( ) No

IF: The answer to Question #20 is No THEN: Jump to Question #22

23) When was the last time that you had oral or anal sex with another man?

( ) During the last month

( ) 1 – 5 months ago

( ) 6 – 12 months ago

( ) More than 12 months ago

( ) Don't know or don't remember

24) Are you currently married to or in a long-term relationship with a man?

( ) Yes

( ) No

IF: The answer to Question #24 is exactly equal to No THEN: Jump to Question #27

25) During the time you have been in this relationship, have you had oral or anal sex with another man other than the man you are married to or in a long-term relationship with?

( ) Yes

( ) No

26) When was the last time you had oral or anal sex with another man?

( ) During the last month

( ) 1 – 5 months ago

( ) 6 – 12 months ago

( ) More than 12 months ago

( ) Don't know or don't remember

27) How would you describe your sexual orientation?

( ) Gay/homosexual/queer

( ) Bisexual

( ) Heterosexual/straight

( ) Other: _________________

( ) Don't Know

The remaining questions in this survey concern voluntary blood donation. By this we mean voluntarily giving blood without being paid. Paid plasma donation does not count.

28) Have you ever donated blood?

( ) Yes

( ) No

( ) Don't know or don't remember

IF: The answer to Question #28 is Yes THEN: Jump to Question #30

29) What were your reasons for not giving blood? You may choose as many reasons from the list below as apply, and you can type any further reasons in 'Some other reason'.

[ ] Too busy

[ ] Fear of needles/pain

[ ] Medical reason, e.g., anemic

[ ] I do not want to give blood

[ ] I've thought about giving blood but never got around to doing it

[ ] I've never really considered giving blood

[ ] I'm not allowed to because I have had oral or anal sex with another man

[ ] I'm not allowed to because I have had other kinds of sexual contact with another man

[ ] I'm not allowed to for other reasons

[ ] Some other reason, Please tell us the reason: _________________________________

[ ] Don't Know

IF: The answer to Question #28 is No THEN: Jump to Question #35

30) How many times have you donated blood since 1977?

( ) None

( ) Once

( ) 2 - 5 times

( ) 6 - 10 times

( ) More than 10 times

( ) Don't know

IF: The answer to Question #30 is None THEN: Jump to Question #35

31) Of the times you have donated blood since 1977, how many were after the first time you had oral or anal sex with another man?

( ) None

( ) Once

( ) 2 – 5 times

( ) 6 – 10 times

( ) More than 10 times

( ) Don't know

32) Have you donated blood at any time in the last 12 months?

( ) Yes

( ) No

33) Have you ever donated blood for any of the following reasons?

	Yes	No
I wanted to donate blood to help someone in need	( )	( )
In response to a TV or radio campaign, or a phone call or letter from the blood bank	( )	( )
I was encouraged or pressured by family, friends, coworkers, or by someone at a blood drive	( )	( )
I wanted to get my blood tested	( )	( )
I wanted to get the incentives for donating that the blood bank was offering	( )	( )

34) Did any of the following factors influence your decision to come to the blood center?

	Yes	No
Blood center testing is confidential	( )	( )
Blood center testing is more accurate than at other test sites	( )	( )
Blood center testing is free	( )	( )
I think that the tests would identify any problem with my blood	( )	( )

33) What other factors influenced your decision to donate blood? (Please Describe)

____________________________________________

35) As far as you are aware, which of the following groups of people are allowed or NOT allowed to give blood under current policies?

	Allowed	Not Allowed	Don’t know
Anyone who has received a blood transfusion in the past year	( )	( )	( )
Anyone who has ever received money, drugs, or other payment for sex	( )	( )	( )
Men who have ever had oral or anal sex with another man	( )	( )	( )
Anyone who has had an accidental needlestick injury in the past year	( )	( )	( )
Anyone who has diabetes	( )	( )	( )
Anyone who has ever injected themselves with drugs not prescribed by a doctor	( )	( )	( )
Anyone who weighs less than 110 lbs.	( )	( )	( )
Anyone who is more than 100 lbs. overweight	( )	( )	( )

36) The tests that blood centers use are no better at correctly identifying who has HIV than the tests used at other testing locations.

( ) Agree Strongly

( ) Agree Moderately

( ) Agree Slightly

( ) Disagree Slightly

( ) Disagree Moderately

( ) Disagree Strongly

( ) Don't Know

37) The tests that blood centers use can detect HIV infection earlier (sooner after infection occurs) than the tests used at other testing locations.

( ) Agree Strongly

( ) Agree Moderately

( ) Agree Slightly

( ) Disagree Slightly

( ) Disagree Moderately

( ) Disagree Strongly

( ) Don't Know

38) Using blood centers as a way to be tested for HIV is a misuse of blood donation.

( ) Agree Strongly

( ) Agree Moderately

( ) Agree Slightly

( ) Disagree Slightly

( ) Disagree Moderately

( ) Disagree Strongly

( ) Don't Know

39. Currently, men who have had sex with another man since 1977 are excluded from blood donation. The policy was introduced because of the increased risk of HIV among men who have sex with men. Other people who also are not allowed to donate blood include people who have had sex in exchange for money or drugs or other payment, people who have injected drugs, and people who weigh less than 110 lbs.

39) Were you aware that any man who has had oral or anal sex with another man, even once, since 1977 is not eligible to donate?

( ) Yes

( ) No

( ) Don't know or don't remember

40) If U.S. researchers conclude that there is very low risk of transmitting HIV from men who have not had sex with a man in the past 5 years, do you think this policy should be amended so that a man who last had oral or anal sex with another man more than five years ago should be allowed to become a blood donor?

( ) Agree Strongly

( ) Agree Moderately

( ) Agree Slightly

( ) Disagree Slightly

( ) Disagree Moderately

( ) Disagree Strongly

( ) Don't Know

41) If U.S. researchers conclude that there is very low risk of transmitting HIV from men who have not had sex with a man in the past year, do you think this policy should be amended so that a man who last had oral or anal sex with another man more than one year ago should be allowed to become a blood donor?

( ) Agree Strongly

( ) Agree Moderately

( ) Agree Slightly

( ) Disagree Slightly

( ) Disagree Moderately

( ) Disagree Strongly

( ) Don't Know

42) Do you think this policy should be amended so that a man who has had sex with another man should be allowed to become a blood donor regardless of when the sexual contact occurred?

( ) Agree Strongly

( ) Agree Moderately

( ) Agree Slightly

( ) Disagree Slightly

( ) Disagree Moderately

( ) Disagree Strongly

( ) Don't Know

43) If U.S. researchers conclude that there is very low risk of transmitting HIV from men who are truly monogamous over the last year, do you think this policy should be amended so that a man who has had sex with only one other man in the last year and is in a truly monogamous relationship should be allowed to become a blood donor?

( ) Agree Strongly

( ) Agree Moderately

( ) Agree Slightly

( ) Disagree Slightly

( ) Disagree Moderately

( ) Disagree Strongly

( ) Don't Know

44) Do you think there are men who have, or have had, oral or anal sex with other men who donate blood despite the current policy that does not allow it?

( ) No, this never happens

( ) Yes, but it rarely happens

( ) Yes, it happens sometimes

( ) Yes, it is fairly common

( ) Yes, it is very common

( ) Don't Know

45) Please tell us why you think men who have had oral or anal sex with other men give blood.

____________________________

____________________________

____________________________

46) Would you give blood if the policy allowed it?

( ) Yes

( ) No

( ) Don't know or don't have an opinion

47) Would you follow a policy placing a temporary ban on blood donations if you had sexual contact with another man in a one-year period before donating blood?

( ) Yes

( ) No

( ) Don't know or don't have an opinion

Please indicate how strongly you agree or disagree with the following statements.

48) Because blood donations are screened, I believe it's safe for me to give blood and I would do so regardless of the policy.

( ) Agree Strongly

( ) Agree Moderately

( ) Agree Slightly

( ) Disagree Slightly

( ) Disagree Moderately

( ) Disagree Strongly

( ) Don't Know

49) If the policy were changed to a defined time period of ineligibility of at least 1-year for men who have had sex with men, I'd be more likely to give blood because the policy that men who have sex with men can never give blood has put me off in the past.

( ) Agree Strongly

( ) Agree Moderately

( ) Agree Slightly

( ) Disagree Slightly

( ) Disagree Moderately

( ) Disagree Strongly

( ) Don't Know

50) If the policy were changed to a defined time period of ineligibility of at least 1-year for men who have had sex with men it would make no difference to whether I give blood.

( ) Agree Strongly

( ) Agree Moderately

( ) Agree Slightly

( ) Disagree Slightly

( ) Disagree Moderately

( ) Disagree Strongly

( ) Don't Know

51) The policy about who can give blood are clear and easy to understand.

( ) Agree Strongly

( ) Agree Moderately

( ) Agree Slightly

( ) Disagree Slightly

( ) Disagree Moderately

( ) Disagree Strongly

( ) Don't Know

52) The current policy that excludes men who have had sex with another man since 1977 should not be changed.

( ) Agree Strongly

( ) Agree Moderately

( ) Agree Slightly

( ) Disagree Slightly

( ) Disagree Moderately

( ) Disagree Strongly

( ) Don't Know

53) The blood bank needs to provide more information and explanation about who can and can't give blood.

( ) Agree Strongly

( ) Agree Moderately

( ) Agree Slightly

( ) Disagree Slightly

( ) Disagree Moderately

( ) Disagree Strongly

( ) Don't Know

54) What other thoughts on this subject would you like to share?

Email Address

55) Please enter your email address. We will send you a $10 Amazon.com gift code to this address.

____________________________________________

Thank you for participating in our research by completing this survey.

Please allow up to 30 days for your $10 Amazon.com electronic gift code to arrive by email. We will do our best to deliver your gift code sooner than this if at all possible.

We will not send you any other email, nor will we share your email address with anyone.

If you have any questions about the study, you may contact us at blood@ucsf.edu

22

OMB number