Form Approved
OMB No. 0920-1080
Expiration Date: XX/XX/XXXX
HIV Outpatient Study (HOPS)
Attachment 3
Behavioral Survey Instrument
Public reporting burden of this collection of information is estimated to average 7 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 (0920-1080)
Attachment 3 Behavioral Survey Instrument
Telephone/Web-ACASI
Please enter participant ID code:
Please press any number key to continue.
Thank you for participating in our short survey.
Please enter your ID number.
*You took this survey on (date) but did not complete it. Would you like to continue the same survey? You can press 1 to continue the same survey or press 2 to start a new survey.
*Only for patients who started a survey within the previous two weeks but did not complete it
Please tell us your sex at birth. Press 1 for female or 2 for male.
Please enter your age:
Thank you. We would like to as you a few questions about things that you have done in the last six months. Some of these questions may seem personal but we encourage you to answer them honestly. Please keep in mind that your answers to these questions are private, and that no one in this clinic will have access to this information. The only information the clinic will receive is whether or not this survey was completed. Your answers will be used to aid medical research about behavior and diseases.
If at any time you do not want to answer a question, and want to skip to the next question, press the pound key. To repeat a question, press the star key. For questions with yes or no answers, press 1 for yes and 0 for no.
For the following questions, a drink of alcohol is defined as 1 can or bottle of beer, 1 glass of wine, 1 can or bottle of wine cooler,1 cocktail or 1 shot of liquor.
During the past 30 days, did you have had at least 1 drink of any alcoholic beverage? If you have had at least one drink in the past 6 months, press 1. If you have not had at least one drink, press 0.
If 0 was pressed, skip to question #12.
If 1 was pressed go to question #9:
How many days per week did you have at least one drink of any alcoholic beverage? Please enter the number of days, from 0 to 7.
On the days when you drank, about how many drinks did you drink on average? Please enter the number
How many times during the past 30 days did you have 5 or more drinks on an occasion? Please enter the number.
Do you currently smoke cigarettes? Please press 1 for yes and 0 for no.
If 0 is pressed, skip to question #14.
If 1 is pressed go to question #13:
Please enter the number of cigarettes you smoke each day.
The next question is about e-cigarettes. These are battery powered devices that usually contain liquid nicotine and don’t produce smoke.
Have you ever used an e-cigarette even one time? Press 1 for yes and 0 for no.
During the past 30 days, how many days did you use an e-cigarette?
The next questions are about smokeless tobacco. Smokeless tobacco products are placed in the mouth or nose and include chewing tobacco, snuff, dip, snus (pronounced snooze) and dissolvable tobacco.
Have you ever used smokeless tobacco, even one time? Press 1 for yes and 0 for no.
During the past 30 days, how many days did you use smokeless tobacco?
In the last 6 months how often did you use pain killers such as Oxycontin, Vicodin, morphine, or Percocet?
More than once a day
Once a day
More than once a week
Once a week or less
Never
If question #18 is NOT “Never” then follow-up question #19
Were all of these pain killers prescribed to you by a doctor? Press 1 for yes and 0 for no.
Before today, have you ever heard of people who do not have HIV taking PrEP, the antiretroviral medicine taken every day for months or years to reduce the risk of getting HIV? Press 1 for yes and 0 for no.
We would like to ask about recreational drug use:
In the last 6 months, have you used marijuana, also known as pot, hash, or cannabis? Press 1 for yes and 0 for no.
If marijuana use in the past 6 months = “Yes” then question #21.
Was any of your marijuana use in the past 6 months recommended by a doctor? Press 1 for yes and 0 for no.
In the last 6 months, have you used cocaine, also known as crack, rock, freebase, or powder? Press 1 for yes and 0 for no.
In the last 6 months, have you used poppers, also known as amyl nitrate, Rush, or leather stripper? Press 1 for yes and 0 for no.
In the last 6 months, have you used heroin, also known as smack? Press 1 for yes and 0 for no.
In the last 6 months, have you used methamphetamines? These drugs are also known as meth, crystal, crystal meth, crank, Tina, or glass. If you have used any of these, Press 1 for yes and 0 for no.
In the last 6 months, have you used “club” or “party” drugs, also known as Ecstasy, Special K, or GBH? Press 1 for yes and 0 for no.
*This question is for men only:
*In the last six months, have you used Viagra, Cialis, or Levitra, either prescribed by a doctor or not? Press 1 for yes and 0 for no.
Have you injected any drugs that were not prescribed by a doctor in the last 6 months? Press 1 for yes and 0 for no.
Thank you for answering these questions. You’re about half-way through now. Please continue.
In the last three days have you missed taking any of your HIV medicines? Press 1 for yes and 0 for no.
If 0 was pressed, skip to question #31.
If 1 is pressed go to question #23:
Please enter the number of doses you have missed in the last 3 days.
We would like to ask the reason you missed taking your medicine. You may have had more than one reason. You can choose yes for as many as apply.
Did you forget to take your medicine? Press 1 for yes and 0 for no.
Did you experience bad side effects from the medicine? Press 1 for yes and 0 for no.
Did you run out of your prescription and choose not to refill it? Press 1 for yes and 0 for no.
Did you run out of your prescription and forget to refill it? Press 1 for yes and 0 for no.
Did you run out of your prescription couldn’t get it refilled when you tried? Press 1 for yes and 0 for no.
Could you not afford the medicine? Press 1 for yes and 0 for no.
Did you have another reason? Press 1 for yes and 0 for no.
The following questions ask about your sexual activities. By sex we mean anything beyond hugging and kissing. This activity could have been done with or without a condom. This includes oral sex, vaginal intercourse, anal intercourse, stimulation by hand, or anything else beyond hugging and kissing. Some of these questions may seem personal, but we encourage you to answer honestly. Please keep in mind that your answers are kept private and will not be shared with anyone in this clinic.
With whom do you usually have sex? For men only press 1, for men and women press 2, for women only press 3.
In the past two years, did you have any sex beyond hugging and kissing? Press 1 for yes and 0 for no.
If 0 is pressed, skip all remaining questions and go to “thank you screen”
*Questions 33 – 56, women only:
Have you had sex in the past 6 months? Press 1 for yes, press 0 for no.
If 0 is pressed, skip all remaining questions and go to “thank you screen”
If 1 is pressed go to question #34.
With how many people?
In the last six months, have you had another person’s penis in your vagina without using a condom? Press 1 for yes, press 0 for no.
If 0 is pressed go to question # 40.
If 1 is pressed, go to question #36:
With how many people?
If some of them were HIV positive, press 1. If none were HIV positive or you don’t know, press 2.
If some of them were HIV negative, press 1. If none were HIV positive or you don’t know, press 2.
If you don’t know the HIV status of some of these partners, press 1. If you know the status of all of these partners, press 2.
In the last six months, have you had another person’s penis in your anus without using a condom? Press 1 for yes, press 0 for no.
If 0 is pressed skip to question #45.
If 1 is pressed, go question #41:
With how many people?
If some of them were HIV positive, press 1. If none were HIV positive or you don’t know, press 2.
If some of them were HIV negative, press 1. If none were HIV positive or you don’t know, press 2.
If you don’t know the HIV status of some of these partners, press 1. If you know the status of all of these partners, press 2.
In the last six months, have you had another person’s penis in your mouth without using a condom? Press 1 for yes, press 0 for no.
If 0 is pressed skip to question #50.
If 1 is pressed, go to question #46:
With how many people?
If some of them were HIV positive, press 1. If none were HIV positive or you don’t know, press 2.
If some of them were HIV negative, press 1. If none were HIV positive or you don’t know, press 2.
If you don’t know the HIV status of some of these partners, press 1. If you know the status of all of these partners, press 2.
In the last six months, have you had another person’s mouth on your vagina without any latex or plastic barriers? Press 1 for yes, press 0 for no.
If 0 is pressed skip to question #55.
If 1 is pressed, go to question #51:
With how many people?
If some of them were HIV positive, press 1. If none were HIV positive or you don’t know, press 2.
If some of them were HIV negative, press 1. If none were HIV positive or you don’t know, press 2.
If you don’t know the HIV status of some of these partners, press 1. If you know the status of all of these partners, press 2.
In the last six months, have you talked about safer sex with any of your sexual partners? Press 1 for yes or 0 for no.
If 0, skip to question #83.
If 1, go to question #56:
How easy or difficult was it for you to talk with your sexual partners about this?
Press 4 for very difficult, 3 for difficult, 1 for easy, or 0 for very easy. If you don’t know, press 9.
*Questions 57 – 82, men only:
Have you had sex in the past 6 months? Press 1 for yes, press 0 for no.
If 0 is pressed, skip all remaining questions and go to “thank you screen.”
If 1 is pressed go to question #58.
With how many people?
In the last six months, have you put your penis in another person’s vagina without using a condom? Press 1 for yes, press 0 for no
If 0 is pressed skip to question #64.
If 1 is pressed, go to question #60:
With how many people?
If some of them were HIV positive, press 1. If none were HIV positive or you don’t know, press 2.
If some of them were HIV negative, press 1. If none were HIV positive or you don’t know, press 2.
If you don’t know the HIV status of some of these partners, press 1. If you know the status of all of these partners, press 2.
In the last six months, have you put your penis in another person’s anus without using a condom? Press 1 for yes, press 0 for no
If 0 is pressed skip to question #69.
If 1 is pressed, go to question #65:
with how many people?
If some of them were HIV positive, press 1. If none were HIV positive or you don’t know, press 2.
If some of them were HIV negative, press 1. If none were HIV positive or you don’t know, press 2.
If you don’t know the HIV status of some of these partners, press 1. If you know the status of all of these partners, press 2.
In the last six months, have you put your penis in another person’s mouth without using a condom? Press 1 for yes, press 0 for no
If 0 is pressed skip to question #74.
If 1 is pressed, go to question #70:
with how many people?
If some of them were HIV positive, press 1. If none were HIV positive or you don’t know, press 2.
If some of them were HIV negative, press 1. If none were HIV positive or you don’t know, press 2.
If you don’t know the HIV status of some of these partners, press 1. If you know the status of all of these partners, press 2.
In the last six months, have you had another person’s penis in your mouth without a condom? Press 1 for yes, press 0 for no
If 0 then skip to question #79.
If 1 is pressed, go to question #75:
with how many people?
If some of them were HIV positive, press 1. If none were HIV positive or you don’t know, press 2.
If some of them were HIV negative, press 1. If none were HIV positive or you don’t know, press 2.
If you don’t know the HIV status of some of these partners, press 1. If you know the status of all of these partners, press 2.
In the last six months, have you had another person’s penis in your anus without a condom? Press 1 for yes, press 0 for no
If 0 then skip to question #84.
If 1 then go to question #80:
with how many people?
If some of them were HIV positive, press 1. If none were HIV positive or you don’t know, press 2.
If some of them were HIV negative, press 1. If none were HIV positive or you don’t know, press 2.
If you don’t know the HIV status of some of these partners, press 1. If you know the status of all of these partners, press 2.
In the last six months, have you talked about safer sex with any of your sexual partners? Press 1 for yes or 0 for no.
If 0, skip to question #86.
If 1, go to question #85:
How easy or difficult was it for you to talk with your sexual partners about this?
Press 4 for very difficult, 3 for difficult, 1 for easy, or 0 for very easy. If you don’t know, press 9.
*These last questions are for both men and women:
How many of these sexual partners you had in the last six months knew you were HIV+? Press 0 for none, 1 for some, and 2 for all.
How many of these sexual partners did you tell, or had you previously told, you were HIV+? Press 0 for none, 1 for some, and 2 for all.
If 0 pressed, then go to “thank you screen” .
If 1 or 2 pressed, go to question #88:
How easy or difficult was it for you to tell these sexual partners that you have HIV? Press 4 for very difficult, 3 for difficult, 1 for easy, or 0 for very easy. If you don’t know, press 9.
Where are you completing this survey?
If you are completing it in the doctor's office, press 1.
If you are completing it at your home, press 2.
If you are completing it at another location, press 3.
Thank you very much for answering our survey. Your answers will be kept private, and will not be shared with anyone in this clinic, but we encourage you to discuss these issues with your clinician. The only information the clinic will receive is that this survey was completed.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | CDC User |
| File Modified | 0000-00-00 |
| File Created | 2021-05-01 |