Form Approved
OMB No. 0920-0572
Expiration Date 03/31/2018
Submission under
0920-0572 Health Message Testing System
Attachment 6: Consumer Brief Survey Instrument
Public reporting burden of this collection of information is estimated to average 15 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: OMB-PRA (0920-0572)
CASE ID_____________
PARTICIPANT SURVEY
We are interested in your opinions about HIV. We would also like to get some additional information about you. If you’re not sure, choose an answer that comes closest to what you think might be true for each question. Please remember that your answers are private. You can choose not to answer any question and can stop at any time.
1. How old are you?
Age__________
a. Prefer not to answer
2. What was your sex assigned at birth?
a. ____Male
b. ____Female
c. ____Intersex/ambiguous
d. ____Don’t know [INELIGIBLE]
e. ____Prefer not to answer [INELIGIBLE]
3. Do you consider yourself to be male, female, or transgender? (check only one)
1 Male
2 Female
3 Transgender Man (or Transmale or Transman)
4 Transgender Woman (or Transfemale or Transwoman)
8 Don’t know [INELIGIBLE]
9 Prefer not to answer [INELIGIBLE]
4. Are you Hispanic or Latino/a
a. ____No
b. ____Yes
c. Prefer not to answer
5. What is your race? (One or more categories may be selected)
a. ____White
b. ____Black or African American
c. ____American Indian or Alaska Native
d. ____Asian
e. ____Native Hawaiian or Other Pacific Islander
f. ___Other [Specify: ____________]
g. Prefer not to answer
6. In what country or territory were you born?
1 United States [SKIP TO S8]
2 Puerto Rico
3 Mexico
4 Cuba
5 Other (Specify: )
9 Prefer not to answer
7. How many years have you been living in the United States? (If less than one year, put a 0 in the space.)
______ years
8. What language are you most comfortable using with your family and friends?
1 English
2 Spanish
3 English and Spanish equally
4 Other (Specify: )
9 Prefer not to answer
9. What is the highest grade or year of school you finished?
a. Never attended school or only attended kindergarten
b. Grades 1 through 8 (elementary)
c. Grades 9 through 11 (some high school)
d. Grade 12 or GED (high school graduate)
e. College 1 year to 3 years (some college or technical school)
f. College 4 years or more (college graduate)
g. Prefer not to answer
10. Which best describes your total personal income during the past year?
1 Less than $20,000
2 $20,001 to $30,000
3 $30,001 to $40,000
4 $40,001 to $50,000
5 $50,001 or more
9 Prefer not to answer
11. Which do you consider yourself to be?
a. Gay, lesbian, homosexual, or same gender loving
b. Bisexual or two spirited
c. Straight or heterosexual
d. Other [Specify:___________________________]
e. None of the above/unsure
f. Prefer not to answer
12. What is your current relationship status? Are you…?
a. Single
b. Married to a man
c. Married to a woman
d. In a relationship with a man
e. In a relationship with a woman
f. Divorced or widowed
g. Prefer not to answer
13. In what ZIP code do you currently live? _________
14. Before being contacted for this study, had you ever heard of CDC or the Centers for Disease Control and Prevention?
a. Yes
b. No
e. Prefer not to answer
15. Please tell us if you agree or disagree with the following statement: I trust the Centers for Disease Control, or CDC, as a source for HIV information.
1 Strongly agree
2 Agree
3 Neither agree nor disagree
4 Disagree
5 Strongly disagree
9 Prefer not to answer
16. What is your job title or role?
[Public Health Professional: e.g. epidemiologist, health communicator, health educator, etc]
[Healthcare Provider: e.g. doctor (MD, DO), nurse, nurse practitioner, physician’s assistant]
[General Consumer: neither a Public Health Professional nor a Healthcare Provider]
[Other:___________]
Behaviors
These next few questions are about your personal behaviors, including sexual activity. Please remember that your answers are kept private.
Sexual Activity
17. Did you have anal sex with any of your male partner(s) in the past [INSERT TIME FRAME]?
a. Yes [1]
b. No [0]
c. Refuse to answer [9]
[If yes…]
18. When you had anal sex with your male partner(s) in the past [INSERT TIME FRAME], how often did you and your partner use a condom?
a. Never used a condom [1]
b. Occasionally used a condom [2]
c. Usually used a condom [3]
d. Always used a condom [4]
e. Refuse to answer [9]
19. In the past [INSERT TIME FRAME], did you ever, even one time, have sex without a condom?
a. Yes [1]
b. No [0]
c. Refuse to answer [9]
20. In the past [INSERT TIME FRAME], how many non-main partners – that is, somebody who you did not consider to be a spouse, significant other, or life partner – did you have oral, vaginal, or anal sex with?
a. 0 [1]
b. 1-5 [2]
c. 6-10 [3]
d. 11-15 [4]
e. 16-20 [5]
f. Over 20 [6]
g. Refuse to answer [9]
21. Did you have unprotected anal sex with any male partners in the past [INSERT TIME FRAME] whose HIV status you didn’t know? By unprotected sex, I mean anal sex when you or your partner didn’t use a condom.
a. Yes [1]
b. No [0]
c. Refuse to answer [9]
22. Did you have unprotected anal sex with any male partners in the past [INSERT TIME FRAME] who you knew or thought to be HIV positive? By unprotected sex, I mean anal sex when you or your partner didn’t use a condom.
a. Yes [1]
b. No [0]
c. Refuse to answer [9]
Sexual Partners
Risk
23. Thinking about the sex you’ve had over the past [INSERT TIME FRAME], do you consider yourself to be high, medium or low risk for getting/transmitting HIV?
a. Low risk [1]
b. Medium risk [2]
c. High risk [3]
d. Refuse to answer [9]
24. Thinking about the sex you’ve had over the past 12 months, do you consider yourself to be low, medium or high risk for getting HIV?
1 Low risk
2 Medium risk
3 High risk
9 Prefer not to answer
25. In the past 12 months, how often did you use condoms for anal sex with your current main sexual partner?
1 Always
2 Usually
3 Occasionally
4 Never
9 Prefer not to answer
26. Some couples develop agreements about whether, when, and with whom sex outside the relationship is okay. Which one of the following scenarios best describes any agreements that you and your main partner have?
1 Both of us cannot have any sex with an outside partner
2 We can have sex with outside partners but with some restrictions
3 We can have sex with outside partners without any restrictions
4 We do not have an agreement
9 Prefer not to answer
27. In the past 12 months, how often did you use condoms for anal sex with casual (non-main) sexual partners?
1 Always
2 Usually
3 Occasionally
4 Never
9 Prefer not to answer
28. Tell me how risky you think each behavior is for [getting OR transmitting] HIV. Use a scale where 0 is lowest risk and 100 is highest risk. Please assign any number in that range to each of the behaviors listed.
a. Deep kissing _____
b. Receptive anal sex (“bottom”) with a condom _____
c. Receptive anal sex (“bottom”) without a condom _____
d. Receptive oral sex (“giving a blow job”) with a condom _____
e. Receptive oral sex (“giving a blow job”) without a condom _____
f. Insertive anal sex (“top”) with a condom _____
g. Insertive anal sex (“top”) without a condom _____
h. Insertive oral sex (“getting a blow job”) with a condom _____
i. Insertive oral sex (“getting a blow job”) without a condom _____
j. Prefer not to answer
28a. [INSERT BEHAVIOR] is [more OR less] risky for [getting OR transmitting] HIV than [INSERT BEHAVIOR].
1 Strongly agree
2 Agree
3 Neither agree nor disagree
4 Disagree
5 Strongly disagree
9 Prefer not to answer
Script: The next few questions are for people living with HIV. Earlier in the survey you reported that you had tested positive for HIV.
29. Are you currently taking antiretroviral medicines to treat your HIV infection?
1 Yes
2 No
9 Prefer not to answer
30. What is the main reason you are not currently taking any antiretroviral medicines?
1 Not currently going to a health care provider for my HIV infection
2 CD4 count and viral load are good
3 Don't have money or insurance for antiretroviral medicines
4 Don't want to take antiretroviral medicines
5 Other [Specify:_____________________]
9 Prefer not to answer
31. Have you ever had an HIV viral load test?
1 Yes
2 No [SKIP TO 8.11]
8 Don’t know [SKIP TO 8.11]
9 Prefer not to answer [SKIP TO 8.11]
30a. What was the result of your most recent viral load test?
1 Undetectable
2 Detectable copies/ml
8 Don’t know
9 Prefer not to answer
32. Before today, have you ever heard of people who do not have HIV taking HIV medicines (PrEP or Truvada) before sex, to keep from getting HIV?
1 Yes
2 No
9 Prefer not to answer
33. Before today, have you ever heard of people who do not have HIV taking HIV medicines (post-exposure prophylaxis, nPEP, or PEP) after sex, to keep from getting HIV?
1 Yes
2 No
9 Prefer not to answer
34. True or False: If someone has HIV and their viral load is “undetectable”, they cannot transmit HIV to other people.
1 True
2 False
9 Prefer not to answer
35. In the past 12 months, have you taken HIV medicines (post-exposure prophylaxis, nPEP or PEP) after sex because you thought it would keep you from getting HIV?
1 Yes
2 No
9 Prefer not to answer
36. In the past 12 months, have you taken HIV medicines (pre-exposure prophylaxis, PrEP or Truvada) before sex because you thought it would keep you from getting HIV?
1 Yes
2 No
9 Prefer not to answer
HIV RISK BEHAVIOR/PREVENTION STRATEGIES
[Perceived risk of HIV infection]
[CURRENT RISK BEHAVIOR/ personal prevention strategies]
37. In the past 12 months, how often did you look for male sexual partners with same HIV status as you?
1 Always
2 Usually
3 Occasionally
4 Never
9 Prefer not to answer
38. In the past 12 months, how often did you use your HIV status and your male partner’s HIV status to determine which sexual activities (i.e., oral and anal intercourse) you would engage in?
1 Always
2 Usually
3 Occasionally
4 Never
9 Prefer not to answer
39. In the past 12 , how often did you use your HIV status and your male partner’s HIV status to determine which sexual roles/positions (i.e., insertive/top or receptive/bottom) you would engage in?
1 Always
2 Usually
3 Occasionally
4 Never
9 Prefer not to answer
Script: Earlier in the survey you reported that you were last tested for HIV in [INSERT DATE from S11].
40. When you got tested in ____/____ [insert date from S11], where did you get tested?
1 Private doctor’s office
2 HIV counseling and testing site
3 Public health clinic/community health clinic
4 Street outreach program/mobile unit
5 Sexually transmitted disease clinic
6 Hospital (inpatient)
7 Correctional facility (jail or prison)
8 Emergency room
9 At home
10 Other
88 Don’t know [INELIGIBLE]
99 Prefer not to answer [INELIGIBLE]
Script: Earlier in the survey you reported that you had never been tested for HIV.
41. Below is a list of reasons why some people have not been tested for HIV. Which of these best describes the most important reason you have not been tested for HIV in the past [INSERT TIME FRAME]? [Check one]
1 I think I am at low risk for HIV infection.
2 I am afraid of finding out that I have HIV.
3 I didn’t have time.
4 Some other reason [Specify: ]
5 No particular reason
9 Prefer not to answer
HIV Awareness and Knowledge
42. Please indicate how much you disagree or agree with the following statements.
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Strongly disagree 1 |
Disagree 2 |
Neither disagree or agree 3 |
Agree 4 |
Strongly agree 5 |
a. I know all I need to know about HIV. |
1 |
2 |
3 |
4 |
5 |
b. I know about how to prevent getting or transmitting HIV. |
1 |
2 |
3 |
4 |
5 |
c. I know whether and how often I should be tested for HIV. |
1 |
2 |
3 |
4 |
5 |
43. Please indicate whether the following statements about HIV are true, false, or if you don’t know the answer.
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True |
False |
Don’t Know |
Prefer not to answer |
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44. There are medications available to treat HIV.
a. Strongly agree [4]
b. Agree [3]
c. Disagree [2]
d. Strongly disagree [1]
e. Don’t know [8]
f. Refuse to answer [9]
45. Because of new treatments for HIV, I think people are taking more sexual risks.
a. Strongly agree [4]
b. Agree [3]
c. Disagree [2]
d. Strongly disagree [1]
e. Don’t know [8]
f. Refuse to answer [9]
46. Because of new treatments for HIV, I’m more willing to have unprotected sex with someone who is HIV negative.
a. Strongly agree [4]
b. Agree [3]
c. Disagree [2]
d. Strongly disagree [1]
e. Don’t know [8]
f. Refuse to answer [9]
47. Because of new treatments for HIV, I’m more willing to have unprotected sex with someone who is HIV positive.
a. Strongly agree [4]
b. Agree [3]
c. Disagree [2]
d. Strongly disagree [1]
e. Don’t know [8]
f. Refuse to answer [9]
48. Please indicate how much you disagree or agree with the following statements.
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Strongly Disagree |
Disagree |
Neither Agree nor Disagree |
Agree |
Strongly Agree |
Prefer not to answer |
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49. Please tell us how much you agree or disagree with each of the following statements: “Someone who is HIV-negative and not taking medicines to prevent HIV (e.g., PrEP/Truvada,) should get tested for HIV every 6 months if they…”
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Strongly disagree 1 |
Disagree 2 |
Neither disagree or agree 3 |
Agree 4 |
Strongly agree 5 |
a. always have sex with a condom. |
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b. have had anal insertive sex (topping) without a condom. |
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c. have had anal receptive sex (bottoming) without a condom. |
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d. have a sex partner who is HIV positive. |
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e. have had anal sex without a condom (receptive or insertive) with a partner whose HIV status they don’t know. |
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f. have had more than one sex partner since their last HIV test. |
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50. On a scale from 1 to 5, where 1 is extremely harmful and 5 is extremely beneficial, how would you rate…
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Extremely Harmful 1 |
Harmful 2 |
Neither Harmful Nor Beneficial 3 |
Beneficial 4 |
Extremely Beneficial 5 |
Refuse to Answer |
a. taking medicines to treat HIV infection (e.g. antiretroviral therapy or ART) to prevent HIV transmission? |
1 |
2 |
3 |
4 |
5 |
9 |
b. taking medicines to prevent HIV [e.g., post-exposure prophylaxis (PEP) or pre-exposure prophylaxis (PrEP)] to prevent HIV?. |
1 |
2 |
3 |
4 |
5 |
9 |
51. Please tell us how much you disagree or agree with each of the following statements: “Taking medicines to prevent HIV….”
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Strongly disagree 1 |
Disagree 2 |
Neither disagree or agree 3 |
Agree 4 |
Strongly agree 5 |
a. is expensive. |
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b. is inconvenient. |
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c. allows me to have unprotected sex with my partner(s) |
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d. is for someone like me. |
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52. Please tell us how much you disagree or agree with each of the following statements: “Taking medicines to treat HIV….”
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Strongly disagree 1 |
Disagree 2 |
Neither disagree or agree 3 |
Agree 4 |
Strongly agree 5 |
a. is expensive. |
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b. is inconvenient. |
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c. allows me to have unprotected sex with my partner(s) |
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d. is for someone like me. |
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53. On a scale from 1 to 5, where 1 is extremely harmful and 5 is extremely beneficial, how would you rate…
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Extremely Harmful 1 |
Harmful 2 |
Neither Harmful Nor Beneficial 3 |
Beneficial 4 |
Extremely Beneficial 5 |
Refuse to Answer |
a. taking medicines to treat HIV infection (e.g. antiretroviral therapy or ART) to prevent HIV transmission? |
1 |
2 |
3 |
4 |
5 |
9 |
b. taking medicines to prevent HIV [e.g., post-exposure prophylaxis (PEP) or pre-exposure prophylaxis (PrEP)] to prevent HIV?. |
1 |
2 |
3 |
4 |
5 |
9 |
Thank you for answering these questions. Please place the survey in the envelope provided. Give the survey and your consent form to the interviewer when you go into the interview room. The interviewer will not see your responses to these questions.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Poehlman, Jon |
| File Modified | 0000-00-00 |
| File Created | 2021-01-25 |