Form Approved
OMB No. 0920-0572
Exp. Date XX/XX/XXXX
Formative Research on the Act Against Aids Campaign - Message, Concept and Materials Testing
Act Against AIDS— HIV Positive Audiences
Public reporting burden of this collection of information is estimated to average 5 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 (0920-0572).
Screening Instrument
Act Against AIDS— HIV Positive Audiences
Procedures for Recording and Limiting Information
Only record information for the questions in the screener. If any informant reveals additional personal information, thank them for being helpful, but guide them back to the screener questions- “That is interesting to learn, but can I now ask you about. . .”
1. What is your gender? (Circle one)
Male
Female
2. In which of the following categories does your age fall: (Circle one)
Under 18 years of age INELIGIBLE: Read script for ineligibles
18–24 years of age
25–34 years of age
35–44 years of age
45–54 years of age
55–64 years of age
65–74 years of age
75 years of age or older
3. What is the highest level of education you have completed? (Circle one)
Grade school
Less than high school graduate/some high school
High school graduate or completed GED
Some college or technical school
Received four-year college degree
Some post graduate studies
Received advanced degree
Other: ____________
4.. Please indicate your race or ethnic background. Are you?
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Race: SELECT ONE OR MORE.
White/Caucasian
Black or African-American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Asian
5. Which of the following categories best describes your total, annual household income? (Circle one)
Under $20,000/year
$20,001–$30,000/year
$30,001–$40,000/year
$40,001–$50,000/year
$50,001–$60,000/year
$60,001–$80,000/year
$80,001–$100,000/year
Over $100,000/year
6. What is your current relationship status? Are you…? (Circle one)
Single
Married to a man
Married to a woman
In a relationship with a man
In a relationship with a woman
Divorced or Widowed
Refused
7. Have you ever had an HIV test? (Circle one)
Yes
No INELIGIBLE: Read script for ineligibles
8. What was the result of your last HIV test? (Circle one)
Positive
Negative INELIGIBLE: Read script for ineligibles
Don’t know INELIGIBLE: Read script for ineligibles
9. Now I am going to ask you to describe your sexual identity. Would you describe yourself as: (Circle one)
Homosexual or “gay” or same gender loving
Bisexual or two spirited
Other, specify ____________________________________
Heterosexual or “straight”
Don’t know
Decline to answer
10. Some people notice information about health on the Internet, even when they are not trying to find out about a health concern they have or someone in the family may have. Have you read such health information on the Internet in the past 12 months? (Circle one)
No
Yes
11. About how often do you use the Internet? (Circle one)
Several times a day
About once a day
3–5 days a week
1–2 days a week
Every few weeks
Less often
Never
Don’t know/refused
IF INDIVIDUAL IS 18 YEARS OR OLDER AND HIV-POSITIVE,
READ INVITATION FOR ELIGIBLE PARTICIPANTS
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | White, Jordan E. (CDC/OID/NCHHSTP) (CTR) |
File Modified | 0000-00-00 |
File Created | 2021-01-25 |