Form 0920-1072 SSuN Gonorrhea and Syphilis Patient Interview & STD Clin

Attachment 8

Data Collection Instruments

STD Surveillance Network (SSuN) Revision Request

OMB# 0920-1072

May 2023

8a: SSuN Gonorrhea and Syphilis Patient Interview

8b: STD Clinic Patient Questionnaire

8a: SSuN Gonorrhea and Syphilis Patient Interview

Suggested Introductory Script – Patient Verbal (Informal) Consent – GC Interview

HELLO, My name is________ and I am calling for the ________________health department about your recent doctor’s appointment with _______________ (mention name & date of patient’s visit to reporting provider/facility).

[Interviewer must assure that they are speaking to the appropriate person by confirming date of birth, date of doctor visit, etc. Local DIS protocols should be followed with respect to initial patient contact and confirmation of patient identity]

We are gathering information about people recently diagnosed with (gonorrhea/syphilis) in ___________________(name of city/state) to help make sure that the best care is available and to help prevent the spread of (gonorrhea/syphilis) in the future. This project is being conducted by the ___________(health department) with funding from and in collaboration with the U.S. Centers for Disease Control and Prevention.

Your name was randomly chosen from among all of the people recently diagnosed and reported to the health department. I would like to ask some questions about your experience at your recent doctor’s visit and about your recent health behaviors related to your diagnosis. These questions should only take about 10 minutes and any information you give me will be kept strictly confidential.

You do not have to answer any question you do not want to, and you can end the interview at any time. Your name will not be shared with anyone and all of the information we gather will be combined with others so that no one individual can ever be identified. Is this a good time for you and would you be willing to help with this important project?

[If patient agrees, go to Module 1, Question 14]

[If patient refuses]We’re sorry you don’t want to participate but thank you very much for your time anyway!

[If patient agrees but states that it is not a good time:]

When would be a good time to call you back? __________________________

Is this the best telephone number to use for you? _______________________________________

[If patient states that they wish to call the interviewer back, provide your name HD affiliation and phone number; ask the patient to confirm approximately when they will call]

Thank you, I look forward to hearing from you on _____________ (day) at ___________(time).

Interviewer Use Only: Was verbal consent obtained for interview? Y N

Form approved:

OMB No. 0920-1072

Expiration date: 10/31/2023

Process Information

1 Interviewer:______________________________ID#________

2 PatientID:___________________________________________

3 EventID:_____________________________________________

Contact Attempts:

4 Date___/___/______; 5 Outcome__________________________________________

Notes:______________________________________________________________________

6 Date___/___/______; 7 Outcome__________________________________________

Notes:______________________________________________________________________

8 Date___/___/______; 9 Outcome__________________________________________

Notes:______________________________________________________________________

10 Date___/___/______; 11 Outcome__________________________________________

Notes:______________________________________________________________________

12 Interview/Disposition Date ___/___/______

13 Phase 3 Investigation Disposition Code:

 00- Investigation complete: patient contacted, interview completed

 01- Investigation complete: patient contacted, partial interview completed

 10- Investigation not complete: Phase 3 investigation pending

 11- Investigation not complete: patient contacted, refused interview

 12- Investigation not complete: patient contacted, language barrier.

 22- Investigation not complete: patient did not respond to any/all interview contact attempts

 33- Investigation not complete: patient contact not initiated because patient resident in correctional, mental health or substance abuse facility.

 44- Investigation not complete: patient contact not initiated because patient is active military on foreign deployment.

 55- Investigation not complete for other reason: Specify __________________

Module 1 - Demographics

Interviewer Read: These first few questions are about you and where you live.

14 What is your age?

____ ____ [code in years]

 888- Refused

14.1 What was your sex at birth (as recorded on your birth certificate)?

Please read choices:[Check only one]

 1- Male

 2- Female

 3- Intersex

Do not read:

 4- Unknown

 9- Refused

15 What Gender do you consider yourself to be…?

Please read choices:[Check only one]

 1- Male (CIS-Man)

 2- Female (CIS-Woman)

 3- Transgender Woman (Transgender M to F)

 4- Transgender Man (Transgender F to M)

Do not read:

 5- Transgender (declined to specify)

 6- Queer, Gender Non-Binary

 8- Refused

16 Do you consider yourself to be Hispanic or Latino/a?

 1- Hispanic (Go to Question 16.1)

 2- Non-Hispanic (Skip to Question 17)

 3- Unknown (Skip to Question 17)

 4- Refused (Skip to Question 17)

17 Which one or more of the following would you say best describes your race?

Please read all choices (except Other): [Check all that apply]

17 White Y N U R

18 Black or African American Y N U R

19 American Indian or Alaska Native Y N U R (If Yes, Go To 19.1)

19.1 Tribal Affiliation (SPECIFY) ______________________________

20 Asian Y N U R (If Yes, Go To 20.1)

21 Native Hawaiian or Other Pacific Islander Y N U R (If Yes, Go To 21.1)

22 Other Race Y N U R (If Yes, Go To 22.1)

22.1 [probe and specify if no other response is appropriate]________________

______________________________________________________________________________

Do not read:

23 Refused all race information Y N

Module 2 – Healthcare Experience

Interviewer Read: These questions are about your recent doctor’s visit (when you were tested for [gonorrhea/syphilis]) and about your access to medical care in general. [Interviewer should mention specific provider, if known]

24 Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare, Indian Health Services, the V.A. or Military?

 1- Yes [GO TO 25]

 2- No [SKIP TO 26]

 3- Don‘t know / Not sure [SKIP TO 26]

 4- Refused [SKIP TO 26]

25 What kind of healthcare insurance do you have?

 1- Private healthcare insurance provided by my employer

 2- Private healthcare insurance I pay for myself

 3- Public healthcare insurance like Medicaid, Medicare, or [insert state-specific Medicaid-like plan name]

 4- Active/retired military or dependent plan like the V.A. or military

 5- Bureau of Indian Affairs/Indian Health Service/Urban Indian Health Board

 7- Other Specify 25.1 ___________________________________

 8- Don‘t know / Not sure

 9- Refused

26 Do you have one person you think of as your personal doctor or health care provider?

If ‘No’, ask: ‘Is there more than one, or is there no person who you think of as your personal doctor or health care provider?’ (Note: if respondent identifies a facility or provider setting rather than individual, then code response as 2)

 1- Yes, only one

 2- More than one (or a facility)

 3- No

 4- Don‘t know / Not sure

 5- Refused

27 Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?

 1- Yes

 2- No

 3- Don‘t know / Not sure

 4- Refused

28 When you went to see _______________ [interviewer: insert reporting provider, clinic or facility name from case report] when you were diagnosed with (gonorrhea/syphilis), did you need to pay anything out-of-pocket, like a co-pay, deductible or cash payment, at the time of your visit? (Note: this question is meant to determine if respondent had to pay any amount of money to the provider at the time of visit; do not include billed amounts or deferred or waived charges.)

 1- Yes

 2- No

 3- Don‘t know /Not sure / Don’t remember

 4- Refused

28.1 Before you went to see _______________ [interviewer: insert reporting provider, clinic or facility name from case report], did you have any unusual discharge or oozing from your (penis/vagina)? (Note: this question is meant to determine if respondent had genital symptoms before their health care visit.)

 1- Yes

 2- No

 3- Don‘t know /Not sure / Don’t remember

 4- Refused

28.2 Before you went to see _______________ [interviewer: insert reporting provider, clinic or facility name from case report], did you notice any unexplained sores or bumps on your (penis/vagina)? (Note: this question is meant to determine if respondent had genital symptoms before their health care visit.)

 1- Yes

 2- No

 3- Don‘t know /Not sure / Don’t remember

 4- Refused

28.3 Before you went to see _______________ [interviewer: insert reporting provider, clinic or facility name from case report], did you have any pain or burning when you urinated? (Note: this question is meant to determine if respondent had genital symptoms before their health care visit.)

 1- Yes

 2- No

 3- Don‘t know /Not sure / Don’t remember

 4- Refused

29 Did you go to the doctor that time because you were having symptoms or pains you thought might be from an STD?

 1- Yes [GO TO 30]

 2- No [SKIP TO 31]

 3- Don‘t know / Not sure / Don’t remember [SKIP TO 31]

 4- Refused [SKIP TO 31]

30 How long did you have these symptoms or pains before you were able to see the doctor? (Note: probe as needed to elicit most specific response.)

 1- 1 Day

 2- 2 to 6 days

 3- 1 to 2 weeks

 4- More than 2 weeks

 5- Don‘t know / Not sure / Don’t remember

 6- Refused

31 Before you went to the doctor that time, did any of your sex partners tell you that you might have been exposed to an STD?

 1- Yes

 2- No

 3- Don‘t know / Not sure / Don’t remember

 4- Refused

44 During that visit, did the doctor, nurse or anyone else talk to you about the importance of getting your sex partners examined and tested for STDs?

 1- Yes

 2- No

 3- Don‘t remember / Not sure

 4- Refused

45 In the time since you found out that you had (gonorrhea/syphilis), have you told any of your sex partners that they may need to be tested or treated for (gonorrhea/ syphilis)?

 1- Yes

 2- No

 3- Don‘t Know / Not sure

 4- Refused

Interviewer Read: “In some places, doctors, nurses or the health department may help you to get your sex partners treated for (gonorrhea/ syphilis) by providing extra medications or prescriptions for your partners.”

46 Did a doctor, nurse or someone at the health department offer to give you medications or a prescription for you to give to any of your sex partner(s)?

 1- Yes [GO TO 47]

 2- No [SKIP TO QUESTION 52]

 3- Don‘t know / Not sure [SKIP TO QUESTION 52]

 4- Refused [SKIP TO QUESTION 52]

47 Who was it that offered you medications or prescriptions for your partners? Was it someone from your doctor’s office, someone from the health department or someone else?

 1- My doctor’s office [GO TO 48]

 2- The health department [GO TO 48]

 3- Someone else [GO TO 48]

 4- Don‘t know / Not sure [GO TO 48]

 5- Refused [SKIP TO QUESTION 52]

48 Did you actually get the medications or prescriptions for your sex partners?

 1- Yes [GO TO 49]

 2- No [SKIP TO QUESTION 52]

 3- Don‘t know / Don’t remember/ Not sure [SKIP TO QUESTION 52]

 4- Refused [SKIP TO QUESTION 52]

49 Did you get extra medicine to give to your partner? Or did you get prescriptions that your partners needed to have filled at a pharmacy?

 1- I got additional medications [GO TO 50]

 2- I got prescription(s) [GO TO 50]

 3- Don‘t know / Not sure [SKIP TO QUESTION 52]

50 Did you give the medications or prescriptions to at least one of your sex partners?

 1- Yes, I gave them to at least one of my partner(s) [GO TO 51]

 2- No, I did not give them to any of my partner(s) [SKIP TO QUESTION 52]

 9- Refused [SKIP TO QUESTION 52]

51 Do you think at least one of your sex partners took this medication?

 1- Yes, I think at least one of my partner(s) took this medicine

 2- No, I do not think any of my partner(s) took these medicines

 9- Refused

52 Did you get tested for HIV at the doctor’s visit when you were tested for (gonorrhea/ syphilis)?

 1- Yes, I got an HIV test at that visit [GO TO 53]

 2- No, I did not get an HIV test [SKIP TO 54]

 3- Don‘t know / Not sure [SKIP TO 54]

 4- Refused [SKIP TO 54]

53 What was the result of your HIV test?

 1- My HIV test was Positive [GO TO 57]

 2- My HIV test was Negative [SKIP TO 58.1]

 3- Don‘t know / Not sure / Didn’t get my results [SKIP TO 58.1]

 4- Refused [SKIP TO 58.1]

54 Have you ever been tested for HIV?

 1- Yes [GO TO 55]

 2- No [SKIP TO 58.1]

 3- Don‘t know / Not sure [SKIP TO 58.1]

 4- Refused [SKIP TO 58.1]

55 When was your last HIV test? Just month and year is ok?

Month ________ [use probes and elicit best guess if patient is not sure]

Year __________ [use probes and elicit best guess if patient is not sure]

[If patient refuses to guess, enter ‘..’ for month and ‘….’ for year.]

56 What was the result of that HIV test?

 1- My HIV test was Positive [GO TO 57]

 2- My HIV test was Negative [SKIP TO 58.1]

 3- Don‘t know /Not sure/Didn’t get results [SKIP TO 58.1]

 4- Refused [SKIP TO 58.1]

57 When was your most recent visit to a doctor, nurse or other health care worker specifically for HIV medical care? Just the month and year is ok.

Month ________ [use probes and elicit best guess if patient is not sure]

Year __________ [use probes and elicit best guess if patient is not sure]

(Note: Enter ‘99’ for month and ‘9999’ for year if patient is still unable to remember; enter ‘88’ and ‘8888’ if patient explicitly refuses to provide date, enter ‘77’ and ‘7777’ if patient has not had first HIV primary care visit yet. DIS should provide referral to HIV care if indicated.)

58 Are you taking antiretroviral medicines to treat your HIV infection?

 1- Yes [FEMALES GO TO 59, MALES SKIP TO 60]

 2- No [FEMALES GO TO 59, MALES SKIP TO 60]

 3- I don‘t know / I am not sure [FEMALES GO TO 59, MALES SKIP TO 60]

 4- Refused [FEMALES GO TO 59, MALES SKIP TO 60]

58.1 When you were diagnosed with (gonorrhea/syphilis), did your health care provider discuss medications to help you prevent getting HIV? This is often called PrEP, or pre-exposure prophylaxis.

 0- No, I am already on PrEP [GO TO 59]

 1- Yes [GO TO 58.2]

 2- No [FEMALES GO TO 59, MALES SKIP TO 60]

 3- Don‘t know / Not sure [FEMALES GO TO 59, MALES SKIP TO 60]

 4- Refused [FEMALES GO TO 59, MALES SKIP TO 60]

58.2 Did your health care provider prescribe medications to help you prevent getting HIV?

 1- Yes [GO TO 58.3]

 2- No [FEMALES GO TO 59, MALES SKIP TO 60]

 3- Don‘t know / Not sure [FEMALES GO TO 59, MALES SKIP TO 60]

 4- Refused [FEMALES GO TO 59, MALES SKIP TO 60]

58.3 Did you fill a prescription or get medications to help you prevent getting HIV?

 1- Yes [GO TO 58.4]

 2- No [FEMALES GO TO 59, MALES SKIP TO 60]

 3- Don‘t know / Not sure [FEMALES GO TO 59, MALES SKIP TO 60]

 4- Refused [FEMALES GO TO 59, MALES SKIP TO 60]

58.4 Are you currently taking medications to help you prevent getting HIV?

 1- Yes [FEMALES GO TO 59, MALES SKIP TO 60]

 2- No [FEMALES GO TO 59, MALES SKIP TO 60]

 3- Don‘t know / Not sure [FEMALES GO TO 59, MALES SKIP TO 60]

 4- Refused [FEMALES GO TO 59, MALES SKIP TO 60]

58.5 Has a doctor or other health care provider ever told you that you had Mpox (monkeypox)?

 1- Yes

 2- No [FEMALES GO TO 59, MALES SKIP TO 59]

 3- I don‘t know / don’t remember/ not sure [FEMALES GO TO 59, MALES SKIP TO 59]

 4- Refused [FEMALES GO TO 59, MALES SKIP TO 59]

58.6 Have you ever received a vaccine for mpox (monkeypox)?

 1- Yes

 2- No [FEMALES GO TO 59, MALES SKIP TO 59]

 3- I don‘t know / don’t remember/ not sure [FEMALES GO TO 59, MALES SKIP TO 59]

 4- Refused [FEMALES GO TO 59, MALES SKIP TO 59]

58.7 How many doses of vaccine for mpox have you received?0

 1 -One

 2- Two

 3- I don‘t know / don’t remember/ not sure

 4- Refused [FEMALES GO TO 59, MALES SKIP TO 60]

58.8 When was your last mpox vaccine shot?

(MM/YYYY) ____/_______

59 Were you pregnant at the time you were told that you had (gonorrhea/ syphilis)?

 1- Yes, I was pregnant at that time

 2- No , I was not pregnant at that time

 3- Don‘t know / Not sure

 4- Refused

Interviewer Read: “The following questions are about your sexual health and behaviors. Not all of these questions may apply to you but we have to ask them for everyone – please let me know if a specific question does not apply and we can move on to the next one. Remember, everything you tell me is strictly confidential and will not be shared except when combined anonymously with the information from all of the other people we talk with.”

Module 3 – Behaviors

60 During the past 12 months, have you had sex with only men, only women, or with both men and women?

 1- Men only  2- Women only

 3- Both men and women  4- Unknown

 9- Refused

60.1 During the past 12 months, have you had sex with a transgender man or transgender woman?

 1- Yes  2- No  3- Don‘t know / Not sure  4- Refused

61 Do you consider yourself to be…?

[Read all choices]

 1- Heterosexual/Straight (not Gay or Lesbian)

 2- Gay/Lesbian/Homosexual

 3- Bisexual

 4- Other/Don’t Know [Do not read]  9- Refused

62 Thinking back to the 3 months before you were diagnosed with (gonorrhea/ syphilis), how many MEN did you have sex with during that time? _________ [Probe: “It’s ok to guess if you don’t know exactly.”]

 9999- Refused

63 Thinking back to the 3 months before you were diagnosed with (gonorrhea/ syphilis), how many WOMEN did you have sex with during that time? _________ [Probe: “It’s ok to guess if you don’t know exactly.”]

 9999- Refused

Based on responses to number of sex partners, EPT questions and to patient’s knowledge of their partner’s treatment status, DIS may facilitate EPT following local protocols at the conclusion of the interview. Please document EPT or other partner services provided to the patient in question 74 at the end of the interview.

Read: Regardless of your previous answers about getting extra medications or prescriptions…

If patient reports only a single sex partner:

63.1 To the best of your knowledge, was your sex partner treated?

 1- Yes, definitely  2- Yes, probably  3- Don‘t know / Not sure  4- No, probably not

 5- Refused

If patient reports multiple sex partners:

63.2 To the best of your knowledge, would you say that all of your sex partners were definitely treated, at least one of your partners was definitely treated, or that none were treated?

 1- All definitely treated  2- At least one definitely treated  3- At least one probably treated

 4- Not sure  5- Probably none treated  6- Refused

64 In the past 12 months, have you given drugs or money in exchange for sex, or received drugs or money in exchange for sex? By sex we mean any vaginal, oral, or anal sex.

 1- Yes

 2- No

 3- Don‘t know / Not sure

 4- Refused

64.1 In the past year, how often have you used prescription pain medications – even if they were not prescribed for you?

 1- Never

 2- Once or Twice

 3- Monthly

 4- Weekly

 5- Daily or Almost Daily

 9- Refused

64.2 In the past year, have you used any injection drugs such as heroin, cocaine or meth?

 1- Yes [GO TO 64.3]

 2- No [SKIP TO 65]

 3- Don’t Know/Can’t Remember [SKIP TO 65]

 4- Refused [SKIP TO 65]

64.3. In the past year, did you inject…(read all, check all that apply)?

 1- Heroin

 2- Cocaine/Crack

 3- Crystal Meth/Methamphetamine/Methadrone

 4- Oxycodone/morphine/Fentanyl/Carfentanil/some other opioid

 5- Other not listed, specify, 64.4 ________________________________

 6- Don’t Know/Can’t Remember

 9- Refused

Interviewer Read: “The next few questions are about the most recent time you had sex and about the person you had sex with. By sex we mean any vaginal, oral or anal sex.”

65 When was the last time you had sex with someone?

 1- In the last week

 2- More than 1 week ago but within the last month

 3- More than 1 month ago but within the last 2 months

 4- More than 2 months ago

 5- Don’t know / Not sure

 9- Refused

66 Thinking back to that last time you had sex, was the person you had sex with…?

Read all, select appropriate response:

 1- Cis-Male

 2- Cis-Female

 3- M-F Transgender

 4- F-M Transgender

Do not read:  5- Unknown

 9- Refused

67 Thinking back to the last person you had sex with, how old do you think that person is? If you don’t know for sure, it’s OK to make your best guess. [Note: probe with age groups, older, younger, etc. Attempt to elicit single number if at all possible.]

_________ (years)

 888- Unknown/Couldn’t Guess

 999- Refused

68 Would you say that person is Hispanic/Latino/a? If you don’t know for sure, it’s OK to make your best guess.

 1- Yes, Hispanic

 2- No, Not Hispanic

 8- I don’t know/Can’t Guess

 9- Refused

69 Thinking back to the last person you had sex with, what race would you say that person is? If you don’t know for sure, it’s OK to make your best guess.

Read all, select best response:

 1- White

 2- Black

 3- AI/AN

 4- ASIAN

 5- NH/OPI

 6- Multiple races

 7- Other race

Do not read:  8- I don’t know/I can’t guess

 9- Refused

70 Thinking back to the last person you had sex with, do you know if that person HIV positive?

 1- I know this person is HIV+

 2- I know this person in HIV-

 3- I don’t know this person’s HIV status

 4- Refused

71 Thinking back to the last person you had sex with; do you think you will have sex with this person again?

 1 Yes

 2 No

 3 Don‘t know / Not sure

 4 Refused

SSuN Interview Conclusion Script

If no additional partner management activity:

That’s all the questions we have – thank you for your time and for your help with this important project. Do you have any questions for me before we end? Remember, everything we talked about today is strictly confidential.

If referring to partner management or eliciting partners: proceed with local partner services protocol.

8b: STD Patient Questionnaire

The __________________ STD clinic is conducting a patient survey to learn more about our patient population and improving our services. All responses will be kept confidential and anonymous. While we would like you to complete the entire survey participants can skip question they don’t want to answer. Thank you for time in completing this survey questionnaire.

1. Is this your first time to this clinic?

[ ] Yes [ ] No

2. Do you feel that this clinic provides a welcoming and respectful environment?

[ ] Yes [ ] No [ ] Not sure

3. What are the reasons for your visit to this clinic today (choose all that apply)?

[ ] Health problem or symptoms

[ ] No health problems or symptoms, but came to get STD screening/check-up

[ ] Told to get checked by partner

[ ] Referred by health department/disease intervention specialist (DIS)

[ ] Follow-up visit

[ ] Came to get STD test results

[ ] Came to get HIV test

[ ] Came to get medication that I can take every day to prevent getting HIV infection before I am exposed to the virus (PrEP)

[ ] Came to get medication that I can take right away because I think I was exposed to HIV in the past few days (PEP)

[ ] Came to get contraception

[ ] Some other reason Please specify ____________________

4. What is the main reason you chose this clinic for care (choose only one)?

[ ] Could walk in or get same day appointment

[ ] Cost

[ ] Privacy concern

[ ] Expert care

[ ] Embarrassed to go to usual doctor

[ ] Some other reason Please specify ______________________

5. Where would you have gone today if this STD clinic did not exist (choose only one)?

[ ] I would have waited to see how I felt and then decided what to do

[ ] Community health center

Form approved:

OMB No. 0920-1072

Expiration date: 10/31/2023

[ ] Public clinic/ health department clinic

[ ] Family planning clinic

[ ] Private doctor’s office

[ ] Urgent care clinic/walk in clinic

[ ] Hospital emergency room (ER)

[ ] Hospital outpatient department

[ ] School-based clinic

[ ] Some other place

Please specify ________________________

6. Is there a place that you USUALLY go to when you are sick or need advice about your health?

[ ] Yes [ ] No  GO TO QUESTION #8

7. If YES, what kind of place do you go to most often (choose only one)?

[ ] Community health center

[ ] Public clinic/health department clinic

[ ] Family planning clinic

[ ] Private doctor’s office

[ ] Urgent care clinic/walk in clinic

[ ] Hospital emergency room (ER)

[ ] Hospital outpatient department

[ ] School-based clinic

[ ] Some other place

Please specify ________________________

8. Is there a place you USUALLY go to when you need routine care or preventive care such as a physical exam or check-up?

[ ] Yes [ ] No  GO TO QUESTION # 10

9. If YES, what kind of place do you go to most often (choose only one)?

[ ] Community health center

[ ] Public clinic/ health department clinic

[ ] Family planning clinic

[ ] Private doctor’s office or HMO

[ ] Urgent care clinic/walk in clinic

[ ] Hospital emergency room (ER)

[ ] Hospital outpatient department

[ ] School-based clinic

[ ] Some other place

Please specify _____________________________

10. Do you have health insurance (choose only one)?

[ ] Yes, parents’ insurance plan

[ ] Yes, government (Medicaid, Medicare, etc.)

[ ] Yes, private insurance (through employer)

[ ] Yes, private insurance (purchased by yourself/healthcare.gov exchange)

[ ] No coverage of any type  GO TO QUESTION # 13

[ ] Don’t know  GO TO QUESTION # 13

11. If YES, would you be willing to use your health insurance for today’s visit?

[ ] Yes  GO TO QUESTION # 13

[ ] No

12. If No, why not (choose all that apply)?

[ ] I do not want my insurance company to know

[ ] Insurance company might send records home

[ ] I do not want my parents/spouse/significant other to know

[ ] Usual doctor might send records home

[ ] I cannot afford to pay the co-pay or deductible

[ ] My insurance will not cover this visit

[ ] Some other reason

Please specify __________________________________

13. What sex were you assigned at birth on your original birth certificate?

[ ] Male

[ ] Female

[ ] Refused

[ ] Don’t know

14. Do you currently describe yourself as male, female, or transgender?

[ ] Male

[ ] Female

[ ] Transgender

[ ] None of these

15. How old are you? Age in years______

16. What is your ethnicity?

[ ] Hispanic or Latino

[ ] Not Hispanic or Latino

17. What is your race (choose all that apply)?

[ ] American Indian or Alaska Native

[ ] Asian

[ ] Black or African American

[ ] Native Hawaiian or Other Pacific Islander

[ ] White

18. Which of the following best represents how you think of yourself?

[ ] Lesbian or gay

[ ] Straight, that is not lesbian or gay

[ ] Bisexual

[ ] Something else

[ ] I don’t know the answer

19. What is your current employment status (choose all that apply)?

[ ] Full-time employment

[ ] Part-time employment

[ ] Unemployed

[ ] Disabled

[ ] Student

[ ] Other

20. What is your highest level of school you have completed or the highest degree you have received ?

[ ] Middle school

[ ] Some high school

[ ] High school diploma

[ ] GED or equivalent

[ ] Some college

[ ] College degree or higher

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Version 15.0 (May 2023)