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pdfForm Approved
OMB No: 0920-New
Exp. Date: XX/XX/XXXX
HIV prevention among Latina transgender women who have sex with men:
Evaluation of a locally developed intervention
Attachment 4c
ChiCAS Questionnaire English
1
HIV Prevention among Latina Transgender Women Who Have Sex with Men:
Evaluation of a Locally Developed Intervention
Baseline and Follow-up Assessment Questionnaire
(NOTE: The Spanish version of the baseline assessment will be used in the
proposed study; this English version is included solely for purposes of review.)
Date:
Interviewer:
Participant ID:
Place and city of interview:
Time interview started:
Time interview completed:
2
Form Approved
OMB No: 0920-New
Exp. Date: XX/XX/XXXX
Privacy Act Statement:
This information is collected under the authority of the Public Health Service Act, Section 301, "Research and Investigation," (42 U.S.C. 241); and
Sections 304, 306 and 308(d) which discuss authority to maintain data and provide privacy for health research and related activities (42 U.S.C. 242 b, k,
and m(d)). This information is also being collected in conjunction with the provisions of the Government Paperwork Elimination Act and the Paperwork
Reduction Act (PRA). This information will only be used by the Centers for Disease Control and Prevention (CDC) staff to evaluate the efficacy of the
locally developed ChiCAS HIV prevention intervention for Hispanic/Latina transgender women.
Public reporting burden of this collection of information is estimated to average 60 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333. Attn: OMB-PRA (0920-New)
Again, we thank you for your time and participation in this assessment. Please remember that when
answering these questions, it is very important to be honest. Some of the items will be very personal.
Questions about your own health and sexual behaviors and feelings of discrimination, as examples,
may be uncomfortable for you, but it is important that you be truthful.
Remember, all the information obtained you provide will be kept private. I am a trained professional
and respect the trust you have given me. I will not make judgments about you or your answers. I will
not tell anyone about what we talked about today and your answers will not be identifiable. Your name
will be removed from the assessment so that others will not know your responses.
Also, there are no right or wrong answers, and we rely on you to be honest. The information that you
provide will ensure the quality of this research. It will help us understand generally what is going on in
the lives of transgender women like you and the needs of the community. It may create opportunities
for new projects that are focused on these community needs. It will help us improve the quality of the
lives of women like you. Simply, it will help us prevent HIV and support access to hormone therapy.
Your honest answers can help us save lives.
Thanks for your participation. I have a few questions for you to get us started.
1) Which of the following best describes your
ethnicity?
1 Hispanic or Latino
0 Not Hispanic or Latino [If not Hispanic or Latino,
skip to end of assessment, item 134]
2) How old are you?
______ years old
[If under 18 years old, skip to end of assessment, item
134]
3) In which language would you consider yourself
to be fluent?
1
2
3
4
4) What sex was on your original birth certificate?
0 Male
1 Female
Only Spanish
More Spanish than English
Both equally
More English than Spanish
[If more English than Spanish, skip to end of
assessment, item 134]
5 Only English
[If only English, skip to end of assessment, item
134]
3
[If female, skip to end of assessment, item 134]
5) How do you describe your gender identity?
0 Male
1 Female
2 Male-to-female transgender (MTF)
3 Female-to-male transgender (FTM)
4 Other gender identity (specify)
________________
[If “male”, “female-to-male transgender”, or
some other specific category that indicates that
they identify as male, skip to end of assessment,
item 134]
6) What was the result of your recent HIV test?
0 Positive
[If “positive”, skip to end of assessment, item 134]
1 Negative
2 I don’t know
3 Indeterminate
4 Never tested
7) In the past 6 months, have you had sex with a
man at least once?
0
No
1 Yes
[If no, skip to end of assessment, item 134]
GENERAL HEALTH & ACCESS TO CARE
The next questions are about your general health and your access to health care.
We are asking this question of everyone just to get a picture of your perception of your health.
8) Compared to other people your age, would you say your health is…
1
2
3
4
5
9) When did you most recently see a medical provider such as a doctor
or nurse in the US for a routine check-up, a routine physical examine,
or something similar, not including an Emergency Department visit?
0
1
2
3
4
10) When did you most recently see a medical provider such as a
doctor or nurse in the US for help with hormone therapy for
feminization?
0
1
2
3
4
11) When did you most recently see a medical provider such as a
doctor or nurse in another country for help with hormone therapy for
feminization?
0
1
2
3
Excellent
Very good
Good
Fair
Poor
Never
Within past 6 months
Within the past year
1-2 years ago
Over 2 years ago
Never
Within past 6 months
Within the past year
1-2 years ago
Over 2 years ago
Never
Within past 6 months
Within the past year
1-2 years ago
4
4
Over 2 years ago
12) What country was that?
BARRIERS TO HEALTH CARE
Have any of the following reasons prevented you from seeking or obtaining general health or medical
care in the US in the past 12 months?
13A) You did not have health insurance.
0 No
1 Yes
13B) The clinic, health department, or hospital was too far away.
0
No
1
Yes
13C) You did not have transportation.
0
No
1
Yes
13D) You could not take time off from work.
0
No
1
Yes
13E) The clinic, health department, or hospital was not open when you could go.
0
No
1
Yes
13F) The staff and providers did not speak your language.
0
No
1
Yes
13G) You were not sure where to go for the services you needed.
0
No
1
Yes
13H) It took too long to get an appointment.
0
No
1
Yes
13I) During previous visits it took too long to see a doctor.
0
No
1
Yes
13J) You felt like you would be treated poorly.
0
No
1
Yes
13K) You didn’t know whether you were eligible to be seen.
0
No
1
Yes
13L) You were concerned about other people finding out about your health.
0
No
1
Yes
13M) You thought that the medical bill would be too high.
0
No
1
Yes
ACCULTURATION
The following section is about language and how you prefer to communicate.
14A) In general, what language(s) do you read and speak?
1 Only Spanish
2 More Spanish than English
3 Both equally
4 More English than Spanish
5 Only English
6 Other language, please specify:
_________________
14B) What was the language(s) you used as a child?
1 Only Spanish
2 More Spanish than English
3 Both equally
5
4 More English than Spanish
5 Only English
6 Other language, please specify:
_________________
14C) What language(s) do you usually speak at home?
1 Only Spanish
2 More Spanish than English
3 Both equally
4 More English than Spanish
5 Only English
6 Other language, please specify:
_______________
14D) In which language(s) do you usually think?
1 Only Spanish
2 More Spanish than English
3 Both equally
4 More English than Spanish
5 Only English
6 Other language, please specify:
_____________
14E) What language(s) do you usually speak with your friends?
1 Only Spanish
2 More Spanish than English
3 Both equally
4 More English than Spanish
5 Only English
6 Other language, please specify:
_____________
14F) In what language(s) are the TV programs you usually watch?
1 Only Spanish
2 More Spanish than English
3 Both equally
4 More English than Spanish
5 Only English
6 Other language, please specify:
______________
14G) In what language(s) are the radio programs you usually listen to?
1 Only Spanish
2 More Spanish than English
3 Both equally
4 More English than Spanish
5 Only English
6 Other language, please specify:
______________
14H) In general, what language(s) are the movies, TV, and radio
programs you prefer to watch and listen to?
1 Only Spanish
2 More Spanish than English
3 Both equally
4 More English than Spanish
5 Only English
6 Other language, please specify:
_____________
6
14I) Your close friends are…
1 All Latinos/Hispanics
2 More Latinos than Americans
3 About half and half
4 More Americans than Latinos
5 All Americans
6 Other, please specify:
______________
14J) You prefer going to social gatherings/parties at which people
are…
1 All Latinos/Hispanics
2 More Latinos than Americans
3 About half and half
4 More Americans than Latinos
5 All Americans
6 Other, please specify:
_____________
14K) The persons you visit or who visit you are…
1 All Latinos/Hispanics
2 More Latinos than Americans
3 About half and half
4 More Americans than Latinos
5 All Americans
6 Other, please specify:
_______________
14L) If you could choose your children’s friends you would want them
to be…
1 All Latinos/Hispanics
2 More Latinos than Americans
3 About half and half
4 More Americans than Latinos
5 All Americans
6 Other, please specify:
_______________
HORMONE THERAPY USE
I want to ask you a bit about your use of transition-related services such as hormone therapy.
Remember that your answers are safe with me. I won’t tell anyone what we talked about today, and
this information will help us plan for future potential projects.
15) Have you ever used hormones for
feminization?
16) Are you currently using hormones for
feminization?
17) When did you first start using hormones for
feminization?
18) When you first started using hormones for
feminization, where did you get them?
0 No
1 Yes
[If no, skip to 21A]
0 No
1 Yes
__________
Month/year
1 Tienda
in US
in your country of origin
Flea
market
in US
3
4 Flea market in your country of origin
2 Tienda
7
Traditional healer (e.g., Curandero, Botanico or
Husero) in US
6 Traditional healer (e.g., Curandero, Botanico or
Husero) in your country of origin
7 Friends in US
8 Friends in your country of origin
9 Family in US
10 Family in your country of origin
11 The internet
12 A medical doctor or nurse in the US prescribed
them and you obtained them at a pharmacy
13 A medical doctor or nurse in your country of
origin prescribed them and you obtained them at a
pharmacy
14 Other, please specify: ____________
5
19) When did you get your most recent hormones
for feminization?
_______________
Month/Year
20A) Where did you get your most recent
hormones for feminization?
1 Tienda
20B) Where did you go to get your most recent
prescription?
99 I
in US
in your country of origin
Flea
market
in US
3
4 Flea market in your country of origin
5 Traditional healer (e.g., Curandero, Botanico or
Husero) in US
6 Traditional healer (e.g., Curandero, Botanico or
Husero) in your country of origin
7 Friends in US
8 Friends in your country of origin
9 Family in US
10 Family in your country of origin
11 The internet
12 A medical doctor or nurse in the US prescribed
them and you obtained them at a pharmacy
13 A medical doctor or nurse in your country of
origin prescribed them and you obtained them at a
pharmacy
14 Other, please specify: ____________
2 Tienda
did not obtain hormones prescribed by a medical
doctor or nurse in the US.
Name of place and provider:
Address:
City:
State:
Zip:
8
20C) What pharmacy did you use to get your most
recent prescription filled?
99 I
did not obtain hormones prescribed by a medical
doctor or nurse in the US.
Name:
Address:
City:
State:
Zip:
HORMONE THERAPY KNOWLEDGE
Please tell me if the following statements are true or false. But don’t worry if you
don’t know an answer; you can also tell me that you don’t know.
21A) Only a medical doctor or nurse can determine the appropriate hormone therapy
and dose.
21B) Transgender women who are taking hormones should have periodic checkups
with a medical doctor or nurse.
21C) It is dangerous to use hormones without supervision of a medical doctor or
nurse.
21D) Hormones obtained from a tienda, the internet, or one’s friends are safe to use.
21E) Using hormones other than as prescribed by a medical doctor or nurse can cause
damage to the kidneys, liver, and heart, and could increase risk for diabetes.
21F) Taking hormones changes the size of one’s adam’s apple.
False
21G) Taking hormones completely eliminates facial hair.
21H) There are places in NC that offer medically supervised hormone therapy for
transgender women at reduce cost without insurance.
21I) A prescription for hormone therapy must be obtained from a medical doctor or
nurse.
True
Don’t
Know
0
1
88
0
1
88
0
1
88
0
1
88
0
1
88
0
1
88
0
1
88
0
1
88
0
1
88
READINESS FOR MEDICALLY SUPERVISED HORMONES
Not at all
likely
A little
likely
Moderately
likely
Very likely
22) How likely is it that you would
initiate medically supervised
1
2
3
4
hormone therapy from a medical
doctor or nurse in the US?
23) Are you planning to initiate medically supervised hormone therapy in the
next 6 months?
24) Are you planning to initiate medically supervised hormone therapy in the
next 30 days?
Extremely
likely
I am already
taking
medically
supervised
hormone
therapy
99
[Skip to
26A]
5
0
No
1
Yes
0
No
1
Yes
9
25) Have you made an appointment with a doctor or at a clinic to obtain
medically supervised hormone therapy?
0
No
1
Yes
BARRIERS TO MEDICALLY SUPERVISED HORMONE THERAPY
Have any of the following reasons prevented you from seeking or obtaining medically supervised
hormone therapy in the US in the past 12 months?
26A) You did not have health insurance.
0 No
1 Yes
26B) The clinic, health department, or hospital was too far away.
0
No
1
Yes
26C) You did not have transportation.
0
No
1
Yes
26D) You could not take time off from work.
0
No
1
Yes
26E) The clinic, health department, or hospital was not open when you could go.
0
No
1
Yes
26F) The staff and providers did not speak your language.
0
No
1
Yes
26G) You were not sure where to go for medically supervised hormone therapy.
0
No
1
Yes
26H) It took too long to get an appointment.
0
No
1
Yes
26I) During previous visits it took too long to see a doctor.
0
No
1
Yes
26J) You felt like you would be treated poorly.
0
No
1
Yes
26K) You didn’t know whether you were eligible to be seen.
0
No
1
Yes
26L) You were concerned about other people finding out about your health.
0
No
1
Yes
26M) You thought that the medical bill would be too high.
0
No
1
Yes
ACCESSING MEDICALLY SUPERVISED HORMONE THERAPY
27) If you wanted to learn more
about hormones for feminization,
where would you go?
28) If you wanted to get a
prescription for hormones for
feminization, where would you go?
88
Don’t
know
88
Don’t
know
HIV KNOWLEDGE
I’d like to ask you about what you know about HIV.
By answering the following questions as honestly as possible, you will help ensure that this and future
projects are meeting the health needs of Latinas like yourself.
Please tell me if the following statements are true or false.
10
False
True
Don’t
Know
29A) HIV is a virus that causes AIDS.
0
1
88
29B) Coughing and sneezing do not spread HIV.
0
1
88
29C) A person can get HIV by sharing a glass of water with someone who has HIV.
0
1
88
0
1
88
0
1
88
0
1
88
0
1
88
0
1
88
29I) There is a vaccine that can stop adults from getting HIV.
0
1
88
29J) An animal skin condom works better against HIV than does a latex condom.
0
1
88
29K) A person will not get HIV if she or he is taking antibiotics.
0
1
88
29L) Vaseline and baby oil are products that should be used with latex condoms.
0
1
88
29M) There is a cure for HIV.
0
1
88
29N) Latinos in the US have higher rates of HIV infection than whites.
0
1
88
29O) During anal sex, the “top” (or insertive partner) is not at risk for HIV.
0
1
88
29P) The southeastern US has higher rates of HIV infection than other regions of the
US.
0
1
88
29Q) North Carolina has one of the fastest growing HIV infection rates in the US.
0
1
88
29R) North Carolina ranks within the top 10 US states with new HIV diagnoses.
0
1
88
29S) Transgender women have higher rates of HIV than than the general population.
0
1
88
29D) Showering, douching, or washing one’s genitals/private parts after sex keeps a
person from getting HIV.
29E) If a man looks good, he doesn’t have HIV.
29F) All pregnant women infected with HIV will have babies born with HIV.
29G) People who have been infected with HIV quickly show physical signs of being
infected.
29H) I am safe from HIV if I only have unprotected sex with married men.
STD KNOWLEDGE
Next are a few statements about sexually transmitted diseases, also known as STDs.
Please tell me if the following statements are true or false.
30A) Someone infected with an STD will always develop symptoms within 2
months.
30B) There is a vaccine that prevents Hepatitis B.
False
True
Don’t
Know
0
1
88
0
1
88
11
30C) It is possible to self-diagnosis for STD infection.
0
1
88
30D) Female infertility can result from an untreated STD.
0
1
88
0
1
88
0
1
88
0
1
88
30H) Chlamydia is the most common bacterial STD in the United States.
0
1
88
30I) There is an STD that can cause cancer.
0
1
88
30J) Genital warts can never be transmitted as long as condoms are used.
0
1
88
30K) Painful urination is a symptom of gonorrhoea.
0
1
88
30L) I was treated for an STD so I am now immune from getting it again.
0
1
88
30M) If someone is being treated for HIV, they cannot get an STD.
0
1
88
30N) Only those with lots of partners are at risk for STD infection.
0
1
88
30O) Syphilis infection in North Carolina is increasing among men who have
sex with men.
0
1
88
30E) People who have another STD, such as herpes, chlamydia, and gonorrhea
are at greater risk for contracting HIV.
30F) People infected with genital herpes (Herpes Simplex Virus-type 2) can only
pass the infection to someone else during the time that they have blisters or sores
in the genital region.
30G) Oral-anal sexual contact (‘rimming’) can spread Hepatitis A infection.
PrEP
One way to prevent HIV is to use a medication called PrEP.
PrEP stands for pre-exposure prophylaxis.
31) Have you heard of PrEP?
32) Are you currently using PrEP?
33) When did you first start using PrEP?
34) When you first started using PrEP,
where did you go to get a prescription?
0
No
1
Yes
0 No
1 Yes
[If no, skip to 38]
__________
Month/year
Name of place and provider:
Address:
City:
State:
Zip:
12
35) Where did you go to get your most
recent prescription?
Name of place and provider:
Address:
City:
State:
Zip:
36) What pharmacy did you use to get
your most recent prescription filled?
Name:
Address:
City:
State:
Zip:
37) In the past seven days, how many
days did you not take PrEP?
38) On a scale from 0 to 10, with 0
being knowing nothing at all and 10
being a lot, how much would you say
you know about PrEP?
[Fill in number here:] __________
0 I took PrEP as prescribed
0
1
(Nothing
at all)
2
3
4
5
6
PrEP KNOWLEDGE
Please tell me if the following statements are true or false. But don’t worry if you
don’t know an answer; you can also tell me that you don’t know.
39A) PrEP can reduce the chances of getting HIV among those without HIV.
7
8
False
9
10
(A lot)
True
Don’t
Know
0
1
88
0
1
88
0
1
88
0
1
88
39E) PrEP is a cure for HIV.
0
1
88
39F) Most people who take PrEP report side effects.
0
1
88
39G) PrEP can be taken with food.
0
1
88
39H) Someone who has HIV should take PrEP.
0
1
88
39I) PrEP interacts with female hormones that some transgender take or plan to take.
0
1
88
39J) To be effective, PrEP must be taken every day.
0
1
88
39B) The medication that is currently approved for use as PrEP is called Truvada.
39C) If taken every day as directed by a doctor, PrEP can be 99% effective against
getting HIV.
39D) PrEP protects against other STDs.
13
39K) A prescription for PrEP must be obtained from a medical doctor or nurse.
0
1
88
39L) Only a pharmacy can provide PrEP.
0
1
88
39M) There are no places available to get PrEP in the local community.
0
1
88
READINESS FOR PrEP
Not at all
likely
40) How likely is it that you’d use PrEP?
A little
likely
1
2
Moderately
likely
3
Very
likely
Extremely
likely
4
I am already
using PrEP
99
5
[Skip to
44A]
41) Are you planning to initiate PrEP use in the next 6 months?
0
No
1
Yes
42) Are you planning to initiate PrEP use in the next 30 days?
0
No
1
Yes
43) Have you made an appointment with a doctor or at a clinic to obtain a prescription
for PrEP?
0
No
1
Yes
BARRIERS TO PrEP
Have any of the following reasons prevented you from seeking or obtaining PrEP in the US in the past
12 months?
44A) You did not have health insurance.
0 No
1 Yes
44B) The clinic, health department, or hospital was too far away.
0
No
1
Yes
44C) You did not have transportation.
0
No
1
Yes
44D) You could not take time off from work.
0
No
1
Yes
44E) The clinic, health department, or hospital was not open when you could go.
0
No
1
Yes
44F) The staff and providers did not speak your language.
0
No
1
Yes
44G) You were not sure where to go to get PrEP.
0
No
1
Yes
44H) It took too long to get an appointment.
0
No
1
Yes
44I) During previous visits it took too long to see a doctor.
0
No
1
Yes
44J) You felt like you would be treated poorly.
0
No
1
Yes
44K) You didn’t know whether you were eligible to be seen.
0
No
1
Yes
44L) You were concerned about other people finding out about your health.
0
No
1
Yes
44M) You thought that the medical bill would be too high.
0
No
1
Yes
14
ACCESSING PrEP
45) If you wanted to learn more
about PrEP, where would you go?
88
Don’t
know
46) If you wanted to get a
prescription for PrEP, where would
you go?
88
Don’t
know
PROVIDER TRUST AND COMMUNICATION
Thinking about doctors in general, please tell me how strongly you agree or disagree with the following
statements.
Strongly
disagree
47A) Sometimes doctors care more about what is convenient for
them than about their patients’ medical needs.
47B) Doctors are extremely thorough and careful.
47C) I completely trust doctors’ decisions about which medical
treatments are best.
47D) A doctor would never mislead me about anything.
47E) All in all, I trust doctors completely.
48A) When all is said and done, I am the person who is responsible
for managing my health.
48B) Taking an active role in my own health care is the most
important factor in determining my health and ability to function.
48C) I am confident that I can take actions that will help prevent or
minimize some symptoms or problems associated with my health.
48D) I know what each of my prescribed medications do.
48E) I am confident that I can tell when I need to go get medical
care and when I can handle a health problem myself.
48F) I am confident I can tell my health care provider concerns I
have even when he or she does not ask.
48G) I am confident that I can follow through on medical treatments
I need to do at home.
48H) I understand my health.
48I) I know the different medical treatment options available for me.
48J) I have been able to maintain the lifestyle changes for my health
that I have made.
48K) I know how to prevent problems with my health.
48L) I am confident I can figure out solutions when situations or
problems arise with my health.
Disagree
Agree
Strongly
agree
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
15
48M) I am confident that I can maintain lifestyle changes even
during times of stress
1
2
3
4
SEXUAL IDENTITY
Now I am going to ask you few more very personal questions about sex and sexual behaviors.
Remember that your responses are private, and you do not have to answer any question you are not
comfortable with. Just be honest.
These questions help us understand the behaviors and needs of Latina women just like you.
49) Which of the following best represents how you
think of yourself?
0
1
2
3
4
Gay (lesbian or gay)
Straight, this is not gay (or lesbian or gay)
Bisexual
Something else
I don’t know the answer
50) What is your current relationship status?
1 Single and not dating anyone special [Skip to 52]
2 Dating someone special and having sex with
other people also
3 Dating someone special and not having sex with
other people
4 Partnered or married and have sex with other
people also
5 Partnered or married and don’t have sex with
other people
51) If dating, partnered, or married, what is that
person’s gender?
0
1
2
3
4
Female
Male
Male to female transgender
Female to male transgender
Other [please specify]: ________________
SEX WITH MEN AND WOMEN
Now, I want to ask you about sex with men. In these next questions when we say “sex” we mean “oral” or
“anal” sex. Oral sex is when someone puts their penis in another person’s mouth. Anal sex is when
someone puts their penis in another person’s anus. Do you understand these terms?
52) How many men have you had sex with in the past 6 months?
________# men
53) How many women have you had sex with in the past 6 months?
________# women
First, I want to ask you about the times that a man put his penis in your anus to have sex.
16
54) About when was the most recent time that a man
put his penis in your anus?
55) Thinking about the most recent time that a man
put his penis in your anus, did he use condoms?
56) Thinking about all the times that a man put his
penis in your anus during the past 30 days, how often
did he use condoms?
57) Thinking about all the times that a man put his
penis in your anus during the past 3 months, how
often did he use condoms?
77 I have never had a man put his penis in my anus.
[Skip to 58]
1 Within the past week
2 Within the past 30 days, but more than a week
ago
3 Over one month ago but within the past 3 months
4 3 months but less than 6 months ago
5 6 months ago but less than a year ago
6 A year or more ago
0
No
1
Yes
77 I have not had a man put his penis in my anus in
the past 30 days.
1 Never
2 Once in awhile
3 About half the time
4 Most of the time
5 Always
77 I have not had a man put his penis in my anus in
the past 3 months.
1 Never
2 Once in awhile
3 About half the time
4 Most of the time
5 Always
Some transgender women have vaginas. If you have a vagina, we want to know about your use of
condoms when a man puts his penis in your vagina.
58) About when was the most recent time that a man
put his penis in your vagina, if you have a vagina?
59) Thinking about the most recent time that a man
put his penis in your vagina, did he use condoms?
60) Thinking about all the times that a man put his
penis in your vagina during the past 30 days, how
often did he use condoms?
77 I have never had a man put his penis in my
vagina or I don’t have a vagina. [Skip to 62]
1 Within the past week
2 Within the past 30 days, but more than a week
ago
3 Over one month ago but within the past 3 months
4 3 months but less than 6 months ago
5 6 months ago but less than a year ago
6 A year or more ago
0
No
1
Yes
77 I have not had a man put his penis in my vagina
in the past 30 days
1 Never
2 Once in awhile
3 About half the time
4 Most of the time
5 Always
17
61) Thinking about all the times that a man put his
penis in your vagina during the past 3 months, how
often did he use condoms?
77 I have not had a man put his penis in my vagina
in the past 3 months
1 Never
2 Once in awhile
3 About half the time
4 Most of the time
5 Always
Some transgender women have penises. If you have a penis, we want to know about your use of
condoms when you have sex with men and women.
First, I want to ask you about the times you put your penis in the anus of a man to have sex.
62) About when was the most recent time that you
put your penis in the anus of a man?
63) Thinking about the most recent time you put your
penis in the anus of a man, did you use condoms?
64) Thinking about all the times you put your penis
in the anus of a man during the past 30 days, how
often did you use condoms?
65) Thinking about all the times you put your penis
in the anus of a man during the past 3 months, how
often did you use condoms?
77 I never have put my penis in the anus of a man
or I don’t have a penis [Skip to 66]
1 Within the past week
2 Within the past 30 days, but more than a week
ago
3 Over one month ago but within the past 3 months
4 3 months but less than 6 months ago
5 6 months ago but less than a year ago
6 A year or more ago
0
No
1
Yes
77 I have not put my penis in the anus of a man in
the past 30 days
1 Never
2 Once in awhile
3 About half the time
4 Most of the time
5 Always
77 I have not put my penis in the anus of a man in
the past 3 months
1 Never
2 Once in awhile
3 About half the time
4 Most of the time
5 Always
Now, I want to ask you about the times you put your penis in the vagina of a woman to have sex.
66) About when was the most recent time that you
put your penis in the vagina of a woman?
77 I never have put my penis in the vagina of a
woman or I don’t have a penis [Skip to 70]
1 Within the past week
2 Within the past 30 days, but more than a week
ago
18
3
4
5
6
67) Thinking about the most recent time you put your
penis in the vagina of a woman, did you use
condoms?
68) Thinking about all the times you put your penis
in the vagina of a woman during the past 30 days,
how often did you use condoms?
69) Thinking about all the times you put your penis
in vagina of a woman during the past 3 months, how
often did you use condoms?
0
Over one month ago but within the past 3 months
3 months but less than 6 months ago
6 months ago but less than a year ago
A year or more ago
No
1
Yes
77 I have not put my penis in the vagina of a
woman in the past 30 days
1 Never
2 Once in awhile
3 About half the time
4 Most of the time
5 Always
77 I have not put my penis in the vagina of a
woman in the past 3 months
1 Never
2 Once in awhile
3 About half the time
4 Most of the time
5 Always
Now, I want to ask you about the times you put your penis in the anus of a woman to have sex.
70) About when was the most recent time that you
put your penis in the anus of a woman?
71) Thinking about the most recent time you put your
penis in the anus of a woman, did you use condoms?
72) Thinking about all the times you put your penis
in the anus of a woman during the past 30 days, how
often did you use condoms?
73) Thinking about all the times you put your penis
in the anus of a woman during the past 3 months,
how often did you use condoms?
77 I never have put my penis in the anus of a
woman or I don’t have a penis [Skip to 74]
1 Within the past week
2 Within the past 30 days, but more than a week
ago
3 Over one month ago but within the past 3 months
4 3 months but less than 6 months ago
5 6 months ago but less than a year ago
6 A year or more ago
0
No
1
Yes
77 I have not put my penis in the anus of a woman
in the past 30 days.
1 Never
2 Once in awhile
3 About half the time
4 Most of the time
5 Always
77 I have not put my penis in the anus of a woman
in the past 3 months.
1 Never
19
2
3
4
5
74) Where did you first meet your most recent male
sex partner?
Once in awhile
About half the time
Most of the time
Always
1
2
3
4
5
6
7
8
Adult bookstore
Through friend(s)
Gay bar / Club
Sex club / Bathhouse
Non-gay bar / Club
Gym / health club / athletic activity
Facebook
Internet dating or social networking site,
including apps like Grindr, Jackd, Adam4Adam,
and badoo
9 Public places including park, shopping mall,
library, public transportation
10 School
11 Social organizations / volunteer service activities
12 Private party or social club
13 Vacation / Business trip
13 Work
14 Grocery store
16 Church, political group
17 Some other way (please specify):
_______________________
CONDOM USE SKILLS
There are certain steps to using a condom correctly.
The following are statements about using a condom, some of which are correct, and some of
which are incorrect. Tell me whether the statement is correct or incorrect.
Correct
Incorrect
Don’t
know
75A) Use a latex condom.
0
1
88
75B) Tear along one side of the foil, being sure not to rip the condom inside.
0
1
88
75C) Put the condom on anytime before ejaculation.
0
1
88
0
1
88
0
1
88
0
1
88
75D) Put the condom on when the penis is erect, before there is any contact
between the penis and the other partner’s anus or vagina.
75E) Completely unroll the condom before placing on the penis.
75F) Withdraw the penis while it is still erect by holding the condom firmly in
place, then remove the condom.
20
75G) If the penis is uncircumcised, pull the foreskin towards the base (hair) of
the penis before putting the condom on.
75H) Use a water-based lubricant (e.g., KY Jelly).
0
1
88
0
1
88
0
1
88
0
1
88
75K) Unroll the condom to the base (hair) of the penis.
0
1
88
75L) Use an oil-based lubricant. (i.e., oil, Vaseline, baby oil)
0
1
88
75M) Check the expiration date on the condom.
0
1
88
75N) Tear the condom package open with your teeth
0
1
88
0
1
88
0
1
88
75Q) Wash the condom to use it again.
0
1
88
75R) Use a lambskin condom.
0
1
88
75I) Squeeze the closed end of the condom between your forefinger and thumb
and unroll the condom over the erect penis.
75J) Wrap the used condom back in the foil to save for the next time.
75O) With one hand pinch the tip of the condom to leave space and prevent air
bubbles, and with the other hand, unroll the condom
75P) Dispose of the used condoms.
CONDOM USE INTENTIONS
Now I am going to read some statements and want you to tell me how likely the following statement is to
occur. You can choose:
Not at all likely; A little likely; Moderately likely; Very likely; and Extremely likely
Not at all
likely
76A) During the next month, you intend to try to
persuade your partner(s) to use condoms every time you
have sex.
76B) You intend to get condoms during the next month.
76C) You intend to always have condoms handy during
the next month.
76D) You intend to use condoms every time you have
sex during the next month.
A little
likely
Moderately
likely
Very
likely
Extremely
likely
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
STD SELF REPORT
Now I’m going to ask questions about specific sexual activities and sexually transmitted diseases.
You can stop and ask me if you don’t understand the names of these diseases.
Have you ever been to a clinic, hospital, health department, or doctor’s office for either of the following?
77) To be tested for sexually transmitted diseases (STDs)
0 No
1 Yes
21
78) To be tested for HIV
0
79) During the past 12 months, have you been to a clinic, hospital, health department,
or doctor’s office to be tested for sexually transmitted diseases (STDs)? This does not
include testing for HIV.
80) During the past 6 months, have you been to a clinic, hospital, health department, or
doctor’s office to be tested for sexually transmitted diseases (STDs)? This does not
include testing for HIV.
81) During the past 12 months, have you been to a clinic, hospital, health department,
or doctor’s office to be tested for HIV?
82) During the past 6 months, have you been to a clinic, hospital, health department, or
doctor’s office to be tested for HIV?
No
1
Yes
0
No
1
Yes
0
No
1
Yes
0
No
1
Yes
0
No
1
Yes
83) Where did you take your most recent HIV
test? (What place or location? Examples include
health department, free clinic, doctor’s office)
84) What was the result of your most recent HIV test?
1
2
3
4
Negative
Positive
Indeterminate
Did not get the result of the most recent past test
Has a doctor or nurse ever told you that you have the following sexually transmitted diseases (STDs)?
If a doctor or nurse has told you, how long ago was the most recent diagnosis:
Never (0)
Less than 1 year ago
(1)
1-5 years ago (2)
More than 5
years ago (3)
85) Gonorrhoea
86) Syphilis
87) Chlamydia
88) Herpes
89) Hepatitis A/B/C
90) HIV / AIDS
91) HPV / Genital Warts
92) Other: ___________
93) In the past 3 months, have you given something to a man in exchange for sex?
(i.e., money, drugs, alcohol, other)
94) In the past 3 months, have you received something from a man in exchange for
sex? (i.e., money, drugs, alcohol, other)
No
Yes
0
1
0
1
22
95) In the past 3 months, have you given something to a woman in exchange for sex?
(i.e., money, drugs, alcohol, other)
96) In the past 3 months, have you received something from a woman in exchange for
sex? (i.e., money, drugs, alcohol, other)
0
1
0
1
BARRIERS TO HIV TESTING
If you have never been tested for HIV, what are the reasons why you have never taken an HIV test? Please
tell me all of the reasons that apply.
97A) I have been tested for HIV [Skip to 98A]
1 Yes
97B) I don’t have health insurance.
1
Yes
1
Yes
1
Yes
97E) I am afraid people will think I'm transgender.
1
Yes
97F) I am afraid people might treat me differently.
1
Yes
97G) I don't have the time.
1
Yes
97H) I don’t have transportation.
1
Yes
97I) I can’t afford it.
1
Yes
97J) I have been practicing safer sex.
1
Yes
97K) I know my sexual partners don't have HIV.
1
Yes
97L) I am not at risk for HIV.
1
Yes
97M) I can’t take time off from work.
1
Yes
97N) I don’t think I am eligible to be seen.
1
Yes
97O) The hours aren’t convenient to my work schedule.
1
Yes
97P) I don’t know where to get tested.
1
Yes
97Q) It is not important.
1
Yes
97R) No one recommended getting tested to me.
1
Yes
97S) Other:_________________________
1
Yes
97C) I am afraid that my result will be reported to the
government
97D) I am afraid I might be HIV positive.
Now think about the past 12 months. If you have not been tested for HIV in the past 12 months, what are the
reasons why you have not taken an HIV test? Please tell me all of the reasons that apply.
98A) I have been tested for HIV in the past 12 months. [Skip to
1 Yes
99A]
23
98B) I don’t have health insurance.
1
Yes
1
Yes
98D) I am afraid I might be HIV positive.
1
Yes
98E) I am afraid people will think I'm transgender.
1
Yes
98F) I am afraid people might treat me differently.
1
Yes
98G) I don't have the time.
1
Yes
98H) I don’t have transportation.
1
Yes
98I) I can’t afford it.
1
Yes
98J) I have been practicing safer sex.
1
Yes
98K) I know my sexual partners don't have HIV.
1
Yes
98L) I am not at risk for HIV.
1
Yes
98M) I can’t take time off from work.
1
Yes
98N) I don’t think I am eligible to be seen.
1
Yes
98O) The hours aren’t convenient to my work schedule.
1
Yes
98P) I don’t know where to get tested.
1
Yes
98Q) It is not important.
1
Yes
98R) No one recommended getting tested to me.
1
Yes
98S) Other:_________________________
1
Yes
98C) I am afraid that my result will be reported to the
government.
PERCEIVED DISCRIMINATION
Now I want to ask you about feeling of discrimination.
How strongly do you agree or disagree with each statement?
Strongly
disagree
99A) Since coming to the US, I often have the feeling that I am being
treated unfairly because of my ethnicity/race.
99B) Since coming to the US, I have experienced violence due to my
ethnicity/race.
99C) Since coming to the US, I have experienced discrimination due
to my ethnicity/race.
Disagree
Agree
Strongly
agree
1
2
3
4
1
2
3
4
1
2
3
4
24
99D) Since coming to the US, I often have the feeling that I am being
treated unfairly because I am transgender.
99E) Since coming to the US, I have experienced violence because I
am transgender.
99F) Since coming to the US, I have experienced discrimination
because I am transgender.
99G) Since coming to the US, I often have the feeling that I am being
treated unfairly because I have sex with men.
99H) Since coming to the US, I have experienced violence because I
have sex with men.
99I) Since coming to the US, I have experienced discrimination
because I have sex with men.
99J) Since coming to the US, I often have the feeling that I am being
treated unfairly because of my documentation status.
99K) Since coming to the US, I have experienced violence due to my
documentation status.
99L) Since coming to the US, I have experienced discrimination due
to my documentation status.
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
SUBSTANCE USE
These next questions ask about substance use. Again, like in all of the questions, it is important to be
honest so that we obtain the most accurate information and can develop the best programs to help
Latinas.
Thinking about drug use over the past 12 months…
Column A
Have you used?
Column B
About how frequently?
[Read response options]
7 Daily
6 5-6 days a week
5 3-4 days a week
4 1-2 days a week
3 Several times a month
2 About once a month
1 Several times in the past 12
months
100) Marijuana
1 Yes→ go to column B
0 No
101) Cocaine
1 Yes→ go to column B
0 No
7 Daily
6 5-6 days a week
5 3-4 days a week
4 1-2 days a week
3 Several times a month
2 About once a month
1 Several times in the past 12
months
102) Crack
1 Yes→ go to column B
0 No
7 Daily
6 5-6 days a week
5 3-4 days a week
25
4 1-2 days a week
3 Several times a month
2 About once a month
1 Several times in the past 12
months
103) Alkyl Nitrites such as
poppers, Rush
1 Yes→ go to column B
0 No
7 Daily
6 5-6 days a week
5 3-4 days a week
4 1-2 days a week
3 Several times a month
2 About once a month
1 Several times in the past 12
months
104) Pain Killers:
Oxycotin, Percocet
1 Yes→ go to column B
0 No
7 Daily
6 5-6 days a week
5 3-4 days a week
4 1-2 days a week
3 Several times a month
2 About once a month
1 Several times in the past 12
months
105) What other Drug: 1
1 __________________
106) What other Drug: 2
2 __________________
7 Daily
6 5-6 days a week
5 3-4 days a week
4 1-2 days a week
3 Several times a month
2 About once a month
1 Several times in the past 12
months
7 Daily
6 5-6 days a week
5 3-4 days a week
4 1-2 days a week
3 Several times a month
2 About once a month
1 Several times in the past 12
months
107A) In the past 12 months, have you ever used a needle or syringe that
was used by someone else, even one time, outside of a medical setting to
inject vitamins, medicines, drugs, or any other substances?
0 No [Skip to 108]
1 Yes
107B) If yes, please specify what substances you injected:
_____________________________
Column A
Column B
26
108) Have you drunk
alcohol in the past 12
months?
About how frequently?
[Read response options]
7 Daily
6 5-6 days a week
5 3-4 days a week
4 1-2 days a week
3 Several times a month
2 About once a month
1 Several times in the past 12
months
1 Yes→ go to column B
0 No
109) In a typical week how many days do you get drunk?
______ Days
99 Don’t drink alcohol
110) Considering all types of alcoholic beverages, how many times
during the past 30 days did you have 5 drinks or more on an occasion?
_____ Times
99 Don’t drink alcohol
111) In the past 30 days, how many times have you been drunk
immediately before or during sex?
112) In the past 30 days, how many times have you been high on
drugs immediately before or during sex?
_____ Times
_____ Times
TRANSPHOBIA
On a scale of 1 to 7, which best describes your response to the following statements?
The following questions are about how you have felt in the last 3 months about being transgender.
Give your first response and don’t spend a lot of time on any of the statements.
113A) Being transgender makes me feel
special and unique.
113B) Being perceived as transgender by
others is okay for me.
113C) I sometimes resent my transgender
identity.
113D) Being transgender makes me feel
like a freak.
113E) I feel isolated and separate from other
transgender people.
113F) I have no problem talking about my
transgenderism to almost anyone.
1
2
3
4
5
6
(Strongly
disagree)
1
2
3
4
5
6
(Strongly
disagree)
1
2
3
4
5
6
2
3
4
5
6
1
7
(Strongly
agree)
2
3
4
5
6
(Strongly
disagree)
(Strongly
disagree)
7
(Strongly
agree)
(Strongly
disagree)
1
7
(Strongly
agree)
(Strongly
disagree)
1
7
(Strongly
agree)
7
(Strongly
agree)
2
3
4
5
6
7
(Strongly
agree)
27
113G) Being transgender is a gift.
1
2
3
4
5
6
(Strongly
disagree)
113H) When I think of being transgender, I
feel depressed.
113I) For me, passing is everything.
1
2
3
4
5
6
(Strongly
disagree)
1
perceived as a woman.
113K) Being read makes me try harder to
pass.
113L) I am like other people but I am also
special because I am transgender.
113M) Passing is my biggest concern.
1
2
3
4
5
6
2
3
4
5
6
2
3
4
5
6
2
3
4
5
6
113O) Often, I feel weird like an outcast or
a pervert.
113P) I often ask myself: Why can't I just
be normal?
113Q) It's much better to pass as female
than to be recognized as transgender.
113R) I sometimes feel that being
transgender is embarrassing.
113S) I am proud to be a transgender
person.
113T) If I look the part, talk the talk, and
walk the walk of a woman, it will allow
others to accept me.
113U) Passing is a standard to measure my
success.
113V) When interacting with members of
the transgender community, I often feel like
I don't fit in.
113W) I envy people who are not
transgender.
1
2
3
4
5
6
2
3
4
5
6
2
3
4
5
6
2
3
4
5
6
2
3
4
5
6
2
3
4
5
6
2
3
4
5
6
2
3
4
5
6
2
3
4
5
6
1
7
(Strongly
agree)
2
3
4
5
6
(Strongly
disagree)
(Strongly
disagree)
7
(Strongly
agree)
(Strongly
disagree)
1
7
(Strongly
agree)
(Strongly
disagree)
1
7
(Strongly
agree)
(Strongly
disagree)
1
7
(Strongly
agree)
(Strongly
disagree)
1
7
(Strongly
agree)
(Strongly
disagree)
1
7
(Strongly
agree)
(Strongly
disagree)
1
7
(Strongly
agree)
(Strongly
disagree)
1
7
(Strongly
agree)
(Strongly
disagree)
1
7
(Strongly
agree)
(Strongly
disagree)
113N) When I think about being
transgender, I feel unhappy.
7
(Strongly
agree)
(Strongly
disagree)
1
7
(Strongly
agree)
(Strongly
disagree)
1
7
(Strongly
agree)
(Strongly
disagree)
1
7
(Strongly
agree)
(Strongly
disagree)
113J) I cannot be happy unless I am
7
(Strongly
agree)
7
(Strongly
agree)
2
3
4
5
6
7
(Strongly
agree)
28
113X) I'm not like other transgender people.
1
2
3
4
5
6
(Strongly
disagree)
113Y) I am comfortable revealing to others
that I am transgender.
113Z) I'd rather have people know
everything and accept me as transgender.
1
2
3
4
5
6
(Strongly
disagree)
1
7
(Strongly
agree)
7
(Strongly
agree)
2
3
4
5
6
(Strongly
disagree)
7
(Strongly
agree)
EMPLOYMENT & EDUCATION
The following questions are about education and income.
114) What is the highest level of education you
reached?
1
2
3
4
5
6
7
8
115) Are you currently in school, not including
ESL?
0 No
1 Yes
116) Are you in school full or part time?
99 I’m not in school
0 Part-time
1 Fulltime
117) What best describes your current
employment status?
1
2
3
4
5
6
7
Less than 5 years of school
5-8 years of school
Less than high school diploma or equivalent (GED)
High school diploma or equivalent (GED)
Some college
2-year college degree
4-year college degree
Master’s degree, professional degree, or more
Employed year round
Employed in seasonal work but not year round
Retired
Unemployed since arrived in US
Unemployed seasonal worker
Unemployed (but not ‘4’ or ‘5’ above)
Disabled and not working
118) Of the following, what types of work have you done the past 12 months in the US? (Please check all that
apply.)
99 Have not worked in US in past 12 months
9 Hair stylist / Barber
1 Animal Slaughtering/ Processing
10 Child care
2 Furniture Manufacturing
11 Clerical / Administrative
3 Other type of factory (list)______________
12 Management
4 Construction
13 Sales / Retail
5 Farming
14 Odd jobs (work done from time to time)
6 Lawn care / Landscaping
15 Cashier
7 Food services (waiter/cook)
16 Bagging groceries
8 Janitor / Industrial Cleaning
17 Other, please specify: _____________
29
119) How much money do you take home each
week?
120) About how much money do you receive
each month from all sources?
$__________ .00
0
1
2
3
4
5
6
None
$1-$99
$100-$499
$500-$999
$1,000-$1,999
$2,000-$2,999
$3000 or more
ETHNIC GROUP PRIDE
Now I am going to read some statements and want you to tell me how much you agree or disagree with
each statement. You can choose:
Strongly disagree; Disagree; Agree; and Strongly agree.
Strongly
disagree
121A) I have spent time trying to find out more about my ethnic
group, such as its history, traditions, and customs.
121B) I am active in organizations or social groups that include
mostly members of my own ethnic group.
121C) I have a clear sense of my ethnic background and what it
means for me.
121D) I think a lot about how my life will be affected by my ethnic
group membership.
121E) I am happy that I am a member of the group I belong to.
121F) I have a strong sense of belonging to my own ethnic group.
121G) I understand pretty well what my ethnic group membership
means to me.
121H) In order to learn more about my ethnic background, I have
often talked to other people about my ethnic group.
121I) I have a lot of pride in my ethnic group.
121J) I participate in cultural practices of my own group, such as
special food, music, or customs.
121K) I feel a strong attachment towards my own ethnic group.
121L) I feel good about my cultural or ethnic background.
Disagree
Agree
Strongly
agree
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
IMMIGRATION & SOCIAL SUPPORT
These are the final set of questions. Thanks for your cooperation and patience!
122) Where were you born?
_________________________________
[city]
30
_________________________________
[region/state/department]
_________________________________
[country]
123) How old were you when you first came to live
in the United States?
124) How long have you lived in the US, total years
and/or months?
_______ Years old
99 I was born in the US
______ [years] _____[months]
125) How long have you lived in NC total years
and/or months?
______ [years] _____[months]
126) What is your current zip code?
_______
127) What city do you live in now?
_________________________________________
We know that answering questions about your life, health, and immigration issues can sometimes be
uncomfortable. As a reminder, the information that we gather in this interview will be kept confidential
and in a safe place, and your name will never be revealed as a participant.
Your answers are important because they will allow us to create projects to help Latinos in this
community to overcome the barriers they face to access health services.
The following questions have to do with your current immigration status, which affects
eligibility for some services.
128A) Do you currently have a “green card”?
128B) Do you currently have a valid student visa, valid tourist visa, work permit, or other
legal immigration status such as deferred action?
128C) Do you have or have you obtained citizenship in the US?
No
Yes
0
1
0
1
0
1
COMMUNITY ATTACHMENT
Not at all
129A) Please indicate how much
you feel a part of or connected to
the gay community.
129B) Please indicate how much
you feel a part of or connected to
the Latino community.
129C) Please indicate how much
you feel a part of or connected to
the Latino gay community.
Very little
A little
Somewhat
Moderately
To a great
extent
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
31
129D) Please indicate how much
you feel a part of or connected to
the transgender community.
129E) Please indicate how much
you feel a part of or connected to
the Latino transgender
community.
0
1
2
3
4
5
0
1
2
3
4
5
The following questions have to do with the possible effects of your documentation status on
your life in the US.
130A) Do you think that your documentation status has limited contact between your family,
friends and you?
130B) Have you ever been questioned about your documentation status?
130C) Do you think you will be deported or questioned about your documentation status if
you go to a social agency or health department?
130D) Do you think you will be deported or questioned about your documentation status if
you go to a clinic for HIV and STDs testing services?
130E) Do you think your documentation status has limited your ability to seek HIV and other
STDs testing services?
130F) Do you avoid the police or other officials because of your documentation status?
130G) Do you find it difficult to find legal services?
No
Yes
0
1
0
1
0
1
0
1
0
1
0
1
0
1
SOCIAL SUPPORT
I am going to read a series of tasks and behaviors. Tell me if you know persons in NC or outside NC,
with whom you are maintaining some form of regular contact, who would perform each helpful
behavior.
No one
would
do this
131A) Comfort you whenever you feel
homesick.
131B) Listen and talk with you whenever you
feel lonely or depressed.
131C) Share your good and bad times.
131D) Spend some quiet time with you
whenever you do not feel like going out.
131E) Spend time chatting with you whenever
you are bored.
131F) Accompany you to do things whenever
you need someone for company.
131G) Visit you to see how you are doing.
131H) Accompany you somewhere even if he
or she doesn’t have to.
Someone
would do
this
A few
would
do this
Several
would do
this
Many would
do this
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
32
131I) Reassure you that you are loved,
supported, and cared for.
131J) Provide necessary information to help
orient you to your new surroundings.
131K) Help you deal with some local
institutions’ official rules and regulations.
131L) Show you how to do something that you
didn’t know how to do.
131M) Explain things to make your situation
clearer and easier to understand.
131N) Tell you what can and cannot be done in
North Carolina.
131O) Help you interpret things that you don’t
really understand.
131P) Give you some tangible assistance in
dealing with any communication or language
problems that you might face.
131Q) Explain and help you understand the
local culture and language.
131R) Tell you about available choices and
options.
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
132) Thank you for participating in this assessment. Is there anything else that you would like to share with us?
INTERVIEWER NOTES
133) Please document any observations or thoughts you have about this interview, the participant, etc. [Skip to
135A]
134) [If the participant was found ineligible as determined from items 1-7 the interviewer should say the
following:] Thank you for your help. I really appreciate your interesting in this study but the information that
you have shared with us indicates that you are not eligible.
[The interviewer should politely terminate the interview.]
33
34
NOTE TO STAFF: Please detach these pages from the rest of the assessment and store in a separate lock
box when completed.
Participant ID: _________
CONTACT INFORMATION
Because we need to get in touch with you in the future for follow-up questions, we want to collect some
information that will help us get in touch with you.
What is your current address?
135A) Street address:
135B) City, State:
135C) Zip code:
135D) What is your current personal cell phone
number?
Is there another way to get in touch with you - maybe
another telephone number and an e-mail address?
135E) Telephone number:
135F) E-mail address:
135G) What about your Facebook name; what is it?
Because you may forget to let us know that you have moved or that your telephone number has
changed, we would like to get some supplemental ways to get in touch with you. We won’t tell them
anything about you or the information you have provide to me, we just want to be able to find you.
Who else would know how to find you?
136A) Name:
136B) Relationship to you:
136C) Street address:
136D) City, State:
136E) Zip code:
136F) Telephone numbers:
35
Can you give me 2 more people who would know how
to find you if we had trouble finding you?
137A) Name:
137B) Relationship to you:
137C) Street address:
137D) City, State:
137E) Zip code:
137F) Telephone numbers:
138A) Name:
138B) Relationship to you:
138C) Street address:
138D) City, State:
138E) Zip code:
138F) Telephone numbers:
I am also giving you a card for you to leave in your wallet that has the telephone number, mailing
address, and e-mail address to get in touch with me in case your cell phone changes or address changes.
NOTE TO STAFF: Please provide a Stay-in-Touch card to the participant.
36
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |