0920-25-0058 MMP Questionnaire

2024 MMP Paper Questionnaire
Version 24.2

OMB No: 0920-0740

Expiration: 05.31.2027

Public reporting burden of this collection of information is estimated to average 40 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, Project Clearance Officer, 1600 Clifton Road,
MS D–74, Atlanta, GA 30329, ATTN: PRA (0920–0740). Do not send the completed form to this address.
CS328379-A

Table of Contents

.............................................................................................................................................................................1
RECRUITMENT (Z)
.............................................................................................................................................................................
Preparation (ZP)
1
.............................................................................................................................................................................
Confidential space (ZS)
2
.............................................................................................................................................................................
Confirmation (ZC)
3
.............................................................................................................................................................................
Age (ZA)
3
.............................................................................................................................................................................
Residence at sampling date (ZR)
4
.............................................................................................................................................................................
Current residence (ZE)
6
.............................................................................................................................................................................
Diagnosis (ZD)
7
.............................................................................................................................................................................
Willingness (ZW)
9
.............................................................................................................................................................................
CONSENT (O)
11
.............................................................................................................................................................................
Consent (OC)
11
.............................................................................................................................................................................
PRELIMINARY INFORMATION (I)
15
.............................................................................................................................................................................
Prior to interview (IP)
15
.............................................................................................................................................................................
Introduction (IN)
17
.............................................................................................................................................................................
ELIGIBILITY CRITERIA (Y)
19
.............................................................................................................................................................................
MMP participation (YM)
19
.............................................................................................................................................................................
Residence (YS)
20
.............................................................................................................................................................................
Age (YA)
23
.............................................................................................................................................................................
BASIC DEMOGRAPHICS (D)
25
.............................................................................................................................................................................
Education (DE)
25
.............................................................................................................................................................................
Race-ethnicity (DR)
25
Sex and sexual
.....................................
o.r.....
ient....
at.io
.....
n ....
(D.G................................................................................................................
)
27
...
.............................................................................................................................................................................
Language ability (DL)
28
.............................................................................................................................................................................
U.S. born (DF)
29
.............................................................................................................................................................................
Incarceration (DJ)
29
.............................................................................................................................................................................
Homeless (DH)
30
.............................................................................................................................................................................
DISABILITY (A)
33
.............................................................................................................................................................................
Disability (AD)
33
.............................................................................................................................................................................
FINANCIAL (F)
35
.............................................................................................................................................................................
Employment (FE)
35
.............................................................................................................................................................................
Income (FI)
35
.............................................................................................................................................................................
Food security (FS)
36
.............................................................................................................................................................................
Healthcare coverage (FH)
36
.............................................................................................................................................................................
GENERAL MEDICAL CARE (J)
39
.............................................................................................................................................................................
Health and well-being (JW)
39
.............................................................................................................................................................................
ER and hospitalizations (JH)
39
.............................................................................................................................................................................
Influenza (JF)
39
.............................................................................................................................................................................
Health literacy (JL)
40
.............................................................................................................................................................................
HIV CARE (K)
41
.............................................................................................................................................................................
Diagnosis date (KD)
41
.............................................................................................................................................................................
Ever care (KE)
42

.............................................................................................................................................................................
Linkage to care (KL)
42
.............................................................................................................................................................................
Care utilization (KU)
44
.............................................................................................................................................................................
Patient-provider relationship (KB)
45
.............................................................................................................................................................................
Barriers and facilitators to care (KP)
46
.............................................................................................................................................................................
HIV TREATMENT AND ADHERENCE (T)
47
.............................................................................................................................................................................
Ever ART (TE)
47
.............................................................................................................................................................................
Current ART (TC)
48
.............................................................................................................................................................................
Adherence (TA)
49
.............................................................................................................................................................................
EMOTIONAL SOCIAL SUPPORT (V)
57
.............................................................................................................................................................................
Emotional social support (VS)
57
.............................................................................................................................................................................
SEXUAL BEHAVIOR (S)
59
.............................................................................................................................................................................
Total sex partners (ST)
59
.............................................................................................................................................................................
Names of partners (SN)
61
.............................................................................................................................................................................
Partner demographics #1 (SP)
63
.............................................................................................................................................................................
Vaginal sex #1 (SV)
64
.............................................................................................................................................................................
Anal sex #1 (SL)
65
.......................
Vaginal or anal sex #1 (SG)
.................................................................................................................... ............6...5
.............................................................................................................................................................................
Status #1 (SS)
66
.............................................................................................................................................................................
Pre-exposure prophylaxis #1 (SR)
66
.............................................................................................................................................................................
Partner demographics #2 (SP)
67
.............................................................................................................................................................................
Vaginal sex #2 (SV)
68
.............................................................................................................................................................................
Anal sex #2 (SL)
69
Vaginal or anal sex #2 (SG).......................................................................................... ....................................
69
.
.............................................................................................................................................................................
Status #2 (SS)
70
.............................................................................................................................................................................
Pre-exposure prophylaxis #2 (SR)
70
.............................................................................................................................................................................
Partner demographics #3 (SP)
71
.............................................................................................................................................................................
Vaginal sex #3 (SV)
72
.............................................................................................................................................................................
Anal sex #3 (SL)
73
.......................
Vaginal or anal sex #3 (SG)............................................................................................................................73
.............................................................................................................................................................................
Status #3 (SS)
74
.............................................................................................................................................................................
Pre-exposure prophylaxis #3 (SR)
74
.............................................................................................................................................................................
Partner demographics #4 (SP)
75
.............................................................................................................................................................................
Vaginal sex #4 (SV)
76
.............................................................................................................................................................................
Anal sex #4 (SL)
77
Vaginal or anal sex #4 (SG)........................................ ....................................................................................7..7.
.............................................................................................................................................................................
Status #4 (SS)
78
.............................................................................................................................................................................
Pre-exposure prophylaxis #4 (SR)
78
.............................................................................................................................................................................
Partner demographics #5 (SP)
79
.............................................................................................................................................................................
Vaginal sex #5 (SV)
80
.............................................................................................................................................................................
Anal sex #5 (SL)
81
Vaginal or anal sex #5 (SG).......................................................................................................................... ...
81.
.............................................................................................................................................................................
Status #5 (SS)
82

.............................................................................................................................................................................
Pre-exposure prophylaxis #5 (SR)
82
.............................................................................................................................................................................
Aggregate information (SA)
83
.............................................................................................................................................................................
VIOLENCE (B)
85
.............................................................................................................................................................................
Physical violence (BP)
85
.............................................................................................................................................................................
Forced Sex (BS)
85
.............................................................................................................................................................................
DEPRESSION AND ANXIETY (M)
87
.............................................................................................................................................................................
PHQ-4 screening questions (MD)
87
.............................................................................................................................................................................
PHQ-8 depression (MA)
88
.............................................................................................................................................................................
GAD-7 anxiety (MG)
89
.............................................................................................................................................................................
ALCOHOL, SMOKING, AND DRUG USE (U)
91
.............................................................................................................................................................................
Alcohol use (UA)
91
.............................................................................................................................................................................
Smoking and vaping (US)
92
.............................................................................................................................................................................
Non-injection drug use (UN)
94
.............................................................................................................................................................................
Injection drug use (UI)
96
.............................................................................................................................................................................
STIGMA AND DISCRIMINATION (R)
101
.............................................................................................................................................................................
Stigma (RS)
101
.............................................................................................................................................................................
Discrimination (RD)
103
.............................................................................................................................................................................
GYNECOLOGICAL AND REPRODUCTIVE HISTORY (G)
105
.............................................................................................................................................................................
Gynecological care (GH)
105
.............................................................................................................................................................................
Family planning (GF)
106
.............................................................................................................................................................................
Reproductive history (GR)
108
.............................................................................................................................................................................
MET AND UNMET NEEDS (N)
111
.............................................................................................................................................................................
Services and assistance programs (ND)
111
.............................................................................................................................................................................
Other disability (NS)
121
.............................................................................................................................................................................
PREVENTION ACTIVITIES (P)
123
.............................................................................................................................................................................
Risk reduction (PR)
123
.............................................................................................................................................................................
HIV treatment as prevention (PB)
123
.............................................................................................................................................................................
INTERVIEW COMPLETION (E)
125
.............................................................................................................................................................................
End of interview (EE)
125
.............................................................................................................................................................................
Referrals and follow-up (EO)
125
.............................................................................................................................................................................
Data validity (EV)
128
.............................................................................................................................................................................
Local questions (EL)
128
.............................................................................................................................................................................
2023 CALENDAR
A-1
.............................................................................................................................................................................
2024 CALENDAR
B-1
.............................................................................................................................................................................
2025 CALENDAR
C-1
.............................................................................................................................................................................
RESPONSE CARDS
D-1

Page |1

Module: Recruitment (Z)
Topic: Preparation (ZP)
Response:

ZP.1.0.
R_INTIDN22 Please enter your Data Collector ID.

(Range: 001-999)
Please enter a number from 001 to 999
Response:

ZP.2.0.

R_INTRON22 Interviewer Note: The following prompts are provided as guidance for staff making initial contact

with a sampled person over the phone. Follow the prompts according to MMP and local project area
guidelines.
Information Needed Before the Call
To confirm a sampled person’s identity over the phone, you should obtain their information before
calling the sampled person. When you contact the sampled person, you will ask them to provide
matching information. Use two or more methods to confirm their identity.
Examples include:
• Full first, middle, and last name (including suffix, if available)
• Date of birth (month, day, and year)
• Medical facility used
• Phone number
• Current or past address
• Social Security Number
In addition, you should check whether the sampled person is aware of their HIV status by looking
into eHARS or other supplementary sources of information. For example, a single report in eHARS
with no subsequent visits to an HIV provider and no additional CD4 or viral load tests may indicate
that the person may not be aware of their status.
1
Continue

ZP.1.0. – ZP.2.0.

Page |2
Response:

ZP.3.0.
R_CONFSPN22

Interviewer Note: The following prompts are provided as guidance for staff making initial
contact with a sampled person over the phone. Follow the prompts according to MMP and
local project area guidelines.
Recruiter: Hi, may I speak to [Insert first name of person]?
If the person is not available and someone else answers:
Recruiter: My name is [Insert your name]. [Insert sampled person’s first name] was chosen
to take part in a health survey. Please have them call me back at [Insert phone number].
Select ‘End Recruitment’
If you reach their voicemail:
Recruiter: Hi, I’m trying to reach [Insert sampled person’s first name]. This is [Insert your
name] from the [HEALTH_DEPT]. You are one of only [SAMPLE_SIZE] people chosen to take
part in our confidential health survey. If you decide to take part, you’ll get [Insert amount
and type of token of appreciation]. Please give me a call at [Insert your phone number].
Thank you.
Select ‘End Recruitment’
If the person is available:
Recruiter: My name is [Insert your name]. I’m calling from the [HEALTH_DEPT] to let you
know that you were selected to take part in our health survey. If you take part, you’ll get
[Insert amount and type of token of appreciation].
1
2

Continue
End Recruitment

Topic: Confidential space (ZS)
Response:

ZS.1.0.

R_CONFSP2N22 Recruiter: Since only people chosen for this survey can take part, I do need to ask you a few

questions to make sure that I am talking to the correct person. To keep your information private,
you need to be in a space where no one can hear your answers. Are you in a private space?
> If YES, select “Next”
> If NO, ask…
Recruiter: Can you get to a private space? I can give you a moment.
> If YES, select “Next”
> If NO, select “End Recruitment” and schedule a call back for a different time
1
Continue
2
End Recruitment

ZP.3.0. – ZS.1.0.

Page |3

Topic: Confirmation (ZC)
Response:

ZC.1.0.

Text2 Intro_R_IDENT1N22 Interviewer Note: The following prompts are provided as guidance for staff making initial contact with
a sampled person over the phone. Follow the prompts according to MMP and local project area
guidelines. Select any of the questions below to validate the respondent’s identity.
• What is your full name (including middle name and/or suffix)?
• What is your date of birth?
• I see you were born in [Insert month]. Can you tell me the year?
• Do you have a regular place or person that you go to for medical care? If yes, what is the name of
that place or person (Interviewer Note: only for persons whose care is confirmed by facility)?
• In my records, I have another phone number for [Insert sampled person’s first and last name] that
begins with (XXX) XXX. Can you tell me the last four digits of that phone number?
• In my records, I have an old address for [Insert sampled person’s first and last name] with the street
number 1437. Can you tell me what street goes with that number?
• I have the first 3 digits of your Social Security # as [Insert first three digits], can you tell me the last 4
digits?
• Would you please show me an ID card or a driver’s license so that I can make sure I am speaking
with the right person (Interviewer Note: only for in-person recruitment)?
R_IDENT1N22 Respondent identity confirmed?
1
Confirmed
2
Not Confirmed
Skip_R_IDENT1N22 If ZC.1.0. (Identity confirmation) =2 (Not confirmed), → ZC.2.0.. Else → R_AGE1N22_24 (Recruitment
age 24).
Response:

ZC.2.0.

R_IDENT2N22 Unfortunately, we cannot move forward because I was not able to confirm your identity. This does

not mean that you can no longer take part in this survey, but we would need some answers for the
questions we just talked about so that you can take part. If you are interested in taking part at a
later date, you can reach me at [Insert health department contact information].
1
End Recruitment

Topic: Age (ZA)
Response:

ZA.1.0.

R_AGE1N22_24 Thank you for confirming your identity. Next, I’ll ask you a few questions to see if you are eligible for
the survey. How old were you on [Recruit_Calculation_CLCSDT_24]?

(Range: 0-150)
If R_AGE1N22_24 is > 150, then say, "Please enter a number from 0 to 150."
Skip_R_AGE1N22_24 If R_AGE1N22_24 = 0-17 → ZA.2.0. (End recruitment age). Else → R_RES1N22_24.
Response:

ZA.2.0.

R_AGE2N22 Thank you for this information. Based on your age, we cannot move forward with the survey, but

thank you for your time.
1
End Recruitment

ZC.1.0. – ZA.2.0.

Page |4

Topic: Residence at sampling date (ZR)
Response:

ZR.1.0.

R_RES1N22_24 What state or territory did you live in on [Recruit_Calculation_CLCSDT_24]?

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49

Alabama (AL)
Alaska (AK)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
District of Columbia (DC)
Florida (FL)
Georgia (GA)
Hawaii (HI)
Idaho (ID)
Illinois (IL)
Indiana (IN)
Iowa (IA)
Kansas (KS)
Kentucky (KY)
Louisiana (LA)
Maine (ME)
Maryland (MD)
Massachusetts (MA)
Michigan (MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)
Montana (MT)
Nebraska (NE)
Nevada (NV)
New Hampshire (NH)
New Jersey (NJ)
New Mexico (NM)
New York (NY)
North Carolina (NC)
North Dakota (ND)
Ohio (OH)
Oklahoma (OK)
Oregon (OR)
Pennsylvania (PA)
Puerto Rico (PR)
Rhode Island (RI)
South Carolina (SC)
South Dakota (SD)
Tennessee (TN)
Texas (TX)
Utah (UT)
Vermont (VT)
Virginia (VA)
Washington (WA)
ZR.1.0. – ZR.1.0.

Page |5

50
West Virginia (WV)
51
Wisconsin (WI)
52
Wyoming (WY)
53
Not living in the United States/Puerto Rico (ZZ)
88
Don't know
77
Refused to answer
SKIP_R_RES1N22 IF ZR.1.0. = AL, AK, AZ, AR, CO, CT, DC, HI, ID, IA, KS, KY, LA, ME, MD, MA, MN, MO, MT, NE, NV, NH,
NM, ND, OH, OK, RI, SC, SD, TN, UT, VT, WV, WI, WY, Not living in US/PR, 88 (Don't know) or 77
(Refused to answer) → ZR.2.0; Else → ZE.1.0.
Response:

ZR.2.0.

R_RES2N22 Thank you for this information. Based on where you live, we cannot move forward with the survey,

but thank you for your time.
1
End Recruitment

ZR.1.0. – ZR.2.0.

Page |6

Topic: Current residence (ZE)
Response:

ZE.1.0.
R_RES3N22 What state or territory do you currently live in?

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49

Alabama (AL)
Alaska (AK)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
District of Columbia (DC)
Florida (FL)
Georgia (GA)
Hawaii (HI)
Idaho (ID)
Illinois (IL)
Indiana (IN)
Iowa (IA)
Kansas (KS)
Kentucky (KY)
Louisiana (LA)
Maine (ME)
Maryland (MD)
Massachusetts (MA)
Michigan (MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)
Montana (MT)
Nebraska (NE)
Nevada (NV)
New Hampshire (NH)
New Jersey (NJ)
New Mexico (NM)
New York (NY)
North Carolina (NC)
North Dakota (ND)
Ohio (OH)
Oklahoma (OK)
Oregon (OR)
Pennsylvania (PA)
Puerto Rico (PR)
Rhode Island (RI)
South Carolina (SC)
South Dakota (SD)
Tennessee (TN)
Texas (TX)
Utah (UT)
Vermont (VT)
Virginia (VA)
Washington (WA)
ZE.1.0. – ZE.1.0.

Page |7

50
West Virginia (WV)
51
Wisconsin (WI)
52
Wyoming (WY)
53
Not living in the United States/Puerto Rico (ZZ)
88
Don't know
77
Refused to answer
Skip_R_RES3N22 If ZE.1.0. (Recruitment_Current Residence) = HI, ID, KS, KY, MO, MN, NE,SD, 88 (Don't know) or 77
(Refused to answer), then → ZE.2.0. (End recruitment_Current residence). Else → ZD.1.0.
(Recruitment_Diagnosis selected).
Response:

ZE.2.0.

R_RES4N22 Thank you for this information. Based on where you live, we cannot move forward with the survey,

but thank you for your time.
1
End Recruitment

Topic: Diagnosis (ZD)
Response:

ZD.1.0.

R_DIAG1N22 Thank you for confirming that information. The reason you were selected for this project is because

you were diagnosed with a health condition that is reported to the state health department.
Can you tell me the health condition or conditions you have been diagnosed with?
Interviewer Note: Do not capture response to this question. Select "Next".
1
Continue
Response:

ZD.2.0.

R_DIAG2N22 Interviewer Note: Did the respondent mention being diagnosed with HIV?

0
No
1
Yes
Skip_R_DIAG2N22 IF ZD.2.0. = 0 (No), then → ZD.3.0.. Else → R_DIAG9N22_24.
Response:

ZD.3.0.

R_DIAG3N22 Would it be alright if I listed some health conditions that are reported to the health department?

You can tell me whether you have been diagnosed with any of these conditions.
0
No
1
Yes
Skip_R_DIAG3N22 IF ZD.3.0. = 1 (Yes), then → ZD.4.0.. Else → ZD.8.0..
Response:

ZD.4.0.

R_DIAG4N22 Interviewer Note: Read each of the questions and allow the respondent to answer. Only capture

their response to the question regarding a diagnosis of HIV.
Have you been diagnosed with meningitis?
1
Continue
Response:

ZD.5.0.
R_DIAG5N22 Have you been diagnosed with tuberculosis?

1

Continue

ZE.1.0. – ZD.5.0.

Page |8
Response:

ZD.6.0.
R_DIAG6N22 Have you been diagnosed with HIV?

0
No
1
Yes
88
Don't know
77
Refused to answer
Skip_R_DIAG6N22 IF ZD.6.0. = 1 (Yes), → ZD.7.0.. Else → ZD.8.0..
Response:

ZD.7.0.
R_DIAG7N22 Have you been diagnosed with measles?

1
Continue
Skip_R_DIAG7N22 IF ZD.7.0. = 1 (Continue), → R_DIAG9N22_24.
Response:

ZD.8.0.

R_DIAG8N22 Unfortunately, based on your answers, we cannot move forward with the survey. Thank you for

your time. I hope you have a great day.
Interviewer Note: Provide local referrals to sampled person as needed.
1
End Recruitment
Response:

ZD.9.0.
R_DIAG9N22_24 Were you first diagnosed with HIV on or before
[INSERT Recruit_Calculation_CLCSDT_24]?

0
No
1
Yes
88
Don't Know
77
Refused to answer
Skip_R_DIAG9N22_24 If R_DIAG9N22_24 (Recruitment diagnosis date 24) = 0 (No), 88 (Don't Know), or 77 (Refused to
answer), → ZD.10.0.. Else → next topic ZW.1.0..
Response:

ZD.10.0.

R_DIAG10N22 Thank you for this information. Based on your date of diagnosis, we cannot move forward with the

survey, but thank you for your time.
1
End Recruitment

ZD.6.0. – ZD.10.0.

Page |9

Topic: Willingness (ZW)
Response:

ZW.1.0.

R_INTERST1N22 Thank you for allowing me to check that you are the right person. As a reminder, this survey is

confidential and will cover some sensitive health information. To keep your information private,
please stay in a location where no one can overhear.
The health survey is called the Medical Monitoring Project or MMP. I will ask you questions about
your health and medical care. Your answers to these questions will be kept private. The
[HEALTH_DEPT] plans to speak with about [SAMPLE_SIZE] people with HIV to better understand
their experiences with medical care in [SITEID] and how we can improve programs and services. For
example, [Interviewer Note: add example of how data from MMP have been applied]. For taking
part, you will receive [$ Interviewer Note: Insert project area token amount here]. Does this sound
like something you would be interested in doing?
0
No
1
Yes
Skip_R_INTERST1N22 If ZW.1.0. = 0 (No), → ZW.2.0.. Else → ZW.3.0..
Response:

ZW.2.0.

R_INTERST2N22 May I ask why you are not interested? Knowing why will help us improve the survey in the future.

Interviewer Note: Address concerns using refusal aversion techniques. If they still refuse, thank the
person for their time and end recruitment. Enter the reason(s) why the participant refused to
participate.
1
End Recruitment
Response:

ZW.3.0.

R_WILL1N22 Great! The survey will take about 60 minutes. Do you have time to complete the survey now over

the phone?
0
No
1
Yes
Skip_R_WILL1N22 IF ZW.3.0. = 0 (No) , → ZW.4.0.. Else → ZW.5.0..

ZW.1.0. – ZW.3.0.

Page |10
Response:

ZW.4.0.

R_WILL2N22 Interviewer Note: Offer a telephone interview first and ask them for a mailing or email address to

send response cards. Only schedule an in person interview if the participant refuses a telephone
interview.
Recruiter: Ok, let’s find a day and time that works for you.
Interviewer Note: Schedule the interview or schedule a time to call them back.
Closing statement for interviews scheduled:
Interviewer Note: Ask the respondent if they will have internet access at the time of the scheduled
interview. If they won’t have internet access or are unsure, offer to mail them the response cards
prior to the interview.
Recruiter: I look forward to speaking with you on [Day of week, Month, Day] at [Time]. I will give you
a phone call at that time.
Thank you so much for your willingness to take part. I hope you have a good rest of your day.
1
End Recruitment
ZW.5.0.

Response:
R_WILL3N22 Now I have a little more information to share with you about the survey and then we can begin.

Please give me a moment to enter some information before we get started.
1
Continue

ZW.4.0. – ZW.5.0.

Page |11

Module: Consent (O)
Topic: Consent (OC)
Response:

OC.1.0.

C_CONSNT1N22 Interviewer Note: Provide a hard copy of the consent form to the participant. Read the following

exactly as written to obtain informed consent.
We chose you for this project because you have HIV. Taking part in this project is up to you. You can
choose to participate or not to participate. You don’t have to be in the project if you don’t want to
be. If you decide to take part, you may leave the project at any time. There are no penalties or loss
of benefits if you choose not to take part or to leave the project early.
[Interviewer Note: If participant is currently incarcerated, add: Taking part in this project will not
affect your parole.]
Your health department and the Centers for Disease Control and Prevention (CDC) are doing this
project to learn more about people living with HIV, including the services they use and need. This
information will help improve programs that keep people healthy and get them the help they need.
If you choose to be in this project, we will ask you questions and look at your medical records.
Answering the questions will take about 40 minutes. You don’t have to answer any question you
don’t want to answer. The questions ask about your:
• medical past
• use of medical and social services
• sex practices
• use of drugs and alcohol
• reproductive history
• ability to work and take care of yourself
If we need more information, a staff member may contact you later.
We send the answers to CDC, but we don’t send them your name. Instead, we will assign a code
number to your answers. We don’t send CDC any information that identifies you. We don’t send
CDC any information that could trace back to you. Your answers are confidential. All project
materials are kept in a locked cabinet or secure computer.
1
Continue

OC.1.0. – OC.1.0.

Page |12
OC.2.0.

Response:
C_CONSNT2N22 We will also look at your medical record to collect information about your HIV. This includes

medicines you are taking, clinic visits, and lab test results. Again, we don’t send CDC any information
that can identify you or that could trace back to you. A code number will link information from your
medical records to your answers.
Supervisors will observe a small number of interviews and medical record reviews to give feedback
to MMP staff on their work.
We protect your privacy. All information you give us will be private and confidential. Your records
will be confidential as much as the law allows. We will group your answers with answers from other
people who take part in this project so that no one will know your answers. We will send CDC
information from this project, but we will not send any information that could identify you. Federal
law protects the confidentiality of information kept at CDC.
You will receive [$ Interviewer Note: Insert project area token amount here] as a token of
appreciation for taking part in the project if you answer the questions and let us review your
medical records. If you later choose to leave the project, you may keep the token of appreciation.
• There is no cost to you other than your time and effort for being in this project.
• If you like, we can give you information about how to avoid giving HIV to someone else.
• If you like, we can give you information about where to get medical and social services.
• There are no direct benefits from being in this project. However, the information you give us can
help us improve services available to other people living with HIV.
• Some of the questions may make you feel uncomfortable or may be too personal. Remember: You
don’t have to answer any questions you don’t wish to answer.
1
Continue
OC.3.0.

Response:
C_CONSNT3N22 If you have questions about this project or your token of appreciation, please ask me or call the

Principal Investigator [Interviewer Note: Insert Principal Investigator] at [Interviewer Note: Insert
phone number].
• If you have questions about your rights and how the project works across the country, please
contact:
• Interviewer Note: If applicable: The institutional review board (IRB) at [Interviewer Note: insert
state/local health department] at [Interviewer Note: insert phone number].
• Interviewer Note: If applicable: [Interviewer Note: insert local IRB contact] at [Interviewer Note:
insert phone number].
• CDC at 1-404-639-6475. Please leave a brief message letting us know how to contact you. Say that
you are calling in reference to the Medical Monitoring Project. Someone will return your call as soon
as possible.
Continue
1
OC.4.0.

Response:
C_CONSNT4N22 Interviewer Note: The sample questions below may be used to confirm competency.

• What questions do you have for me?
• I want to make sure we have some understanding about this project. Can you tell me what this
project is about in your own words?
• What do you expect to gain?
• What should you do if you agree to participate, but later change your mind?
• What should you do if you have any questions or concerns about participating?
1
Continue
OC.2.0. – OC.4.0.

Page |13
Response:

OC.5.0.
C_CONSNT5N22 Do you agree to participate in this project?

Interviewer Note: Did the participant consent?
By clicking “Consented”, you are confirming that the respondent gave you verbal informed consent
to participate in MMP in compliance with all federal, state, and local requirements.
1
Consented
2
Did not consent
Skip_C_CONSNT5N22 IF OC.5.0. = 2 (Did not consent), → OC.6.0.. Else → OC.7.0..
Response:

OC.6.0.

C_NOCONSNTN22 Interviewer Note: Thank the participant for their time and follow procedures to close out interview.

1

End interview
Response:

OC.7.0.
C_INTERNTN22 Do you have internet access?

Interviewer Note: If they have internet access, help them locate the online response cards at
4MMP.cdc.gov. If they do not have access to the internet and you believe you may lose the
interview if you schedule it later, continue with the interview and be prepared to read aloud the
response card options to the participant.
1
Continue

OC.5.0. – OC.7.0.

Page |15

Module: Preliminary information (I)
Topic: Prior to interview (IP)
IP.1.0.
Calculation_IDATEAVN21 Automatically calculate interview date based on device date

Response:

IP.1.1.
Intro_IDATEVERN21_24 Enter the following information prior to the interview.
Text2

IDATEVERN21_24 Today's date is [Insert Calculation_IDATEAVN21]. If this is correct, select “Interview date is correct.” If this is
incorrect, exit Voxco and change the date on your device. If the date cannot be fixed on your device, select
“Interview date is incorrect.”

1
2

Interview date is correct
Interview date is incorrect
Response:

IP.1.2.
Skip_IDATECHECKN21 If IDATEVERN21_24 = 1, → IP.1.2.. Else, → IDATECHECK21.

IDATECHECKN21 If you cannot change the date on your device, please enter the correct date.

(Range: 06/01/2024 - 05/31/2027)
Read "Interview date has been updated to [Insert IP.1.1.]. If this is not correct, use "Previous
Question" button to go back and correct."
IP.1.3.
Calculation_IDATE If the device date is correct, use Calculation_IDATEAVN21 for interview date. Otherwise, use the

manually entered date [IDATECHECKN21].
IP.1.4.
Calculation_IDATE7 Calculate the date 7 days prior to IDATE (interview date). Example, if IDATE is 12/08/2026, then

IDATE7 is 12/01/2026. Coding should take into account leap years.
IP.1.5.
Calculation_IDATE12 Calculate the date 12 months prior to IDATE (interview date). Example, if IDATE is 12/02/2026, then

IDATE12 is 12/02/2025. Coding should take into account leap years.
IP.1.6.
Calculation_LASTYEAR Calculate last calendar year: LASTYEAR= (Current year) - 1.

IP.1.7.
Calculation _SHIDATE21 String version of the interview date. SHORTDATE(IDATE)

Response:

IP.2.0.
Calculation_CLCSDT_24 IDATE CLCSDT_24

June 1, 2024 – May 31, 2025
June 1, 2025 – May 31, 2026
June 1, 2026 – May 31, 2027
June 1, 2027 – May 31, 2028
June 1, 2028 – May 31, 2029

12/31/2023
12/31/2024
12/31/2025
12/31/2026
12/31/2027

IP.1.0. – IP.2.0.

Page |16
Response:

IP.2.1.

Calculation_CYGSN5_24 Calculate cycle year using CYGSN5_24 (cycle year based on interview date)

If IDATE is June 1, 2024 – May 31, 2025, then CYGSN5_24=2024
If IDATE is June 1, 2025 – May 31, 2026, then CYGSN5_24=2025
If IDATE is June 1, 2026 – May 31, 2027, then CYGSN5_24=2026
If IDATE is June 1, 2027 – May 31, 2028, then CYGSN5_24=2027
If IDATE is June 1, 2028 – May 31, 2029, then CYGSN5_24=2028
Response:

IP.3.0.
SURVEYMODEN24

Is this a telephone or in-person interview? [SELECT ONLY ONE.]
1
2

Telephone interview
In-person interview
Response:

IP.4.0.
MODEADM Was the interview originally administered on paper?

0
1

No
Yes
Response:

IP.5.0.
PRISONSETN24

Is the respondent currently in prison or jail? [SELECT ONLY ONE.]
0
1

No
Yes
Response:

IP.6.0.

INTERPN8 [DON'T READ ALOUD] Are you using a language interpreter for this interview?

0
No
1
Yes
Skip_24_INTERPN8 If IP.7.0. = 0 (no), → IP.3.0.. Else, → IP.7.1..
Response:

IP.6.1.

INTLAN8 [DON'T READ ALOUD] What language is the interpreter using for this interview?

1
2
3
4
5
6
7
8

Spanish
French
German
Chinese
Creole (French or Haitian)
American Sign Language (ASL)
Arabic
Other
Response:

IP.7.0.
SITEID Site ID of jurisdiction where person was sampled:

Valid numbers are as follows: 0006, 1600, 0010, 0012, 0013, 3360, 0017, 0018, 4480, 0026, 0028,
0034, 0036, 5600, 0037, 0041, 0042, 6160, 0072, 7360, 0048, 0051, and 0053. Else read, “Site ID is
invalid.” Return to IP.3.0..
If IP.3.0. is less than 4 digits, then read, "Number must be 4 digits." Return to IP.3.0..

IP.2.1. – IP.7.0.

Page |17
Response:

IP.7.2.

IJURN5 [DON'T READ ALOUD] What is the site ID of the jurisdiction completing the interview?

(Range: 0001–9999)
Valid numbers are as follows: 0006, 1600, 0010, 0012, 0013, 3360, 0017, 0018, 4480, 0026, 0028,
0034, 0036, 5600, 0037, 0041, 0042, 6160, 0072, 7360, 0048, 0051, and 0053. Else, read “The site ID
of the jurisdiction completing the interview is invalid.” Return to IP.6.0..
If IP.6.0. is less than 4 digits, then read, "Number must be 4 digits." Return to IP.6.0..
Response:

IP.7.3
INDID Respondent ID:

(Range: 0001-9999)
If number is less than 4 digits, then read, “Number must be four digits.” Return to IP.3.3..
Response:

IP.7.4.

Calculation_24_PARID Calculate PARID (participant ID) by combining SITEID (side ID where person sampled) and 09 and last

two digits of CYGSN5_24 (cycle year based on date of interview) and INDID (respondent ID).
(Range: 0000-0000-0001 to 9999-9999-9999)
Response:

IP.7.5.

IDCONFN3_24 [DON'T READ ALOUD] The Participant ID is [SITEID]-[09 and last 2 digits of CYGSN5_24]-[INDID]. Is

that correct?
0
No
1
Yes
If IDCONFN3_24 is 0 (no), then read, Interviewer: Please re-enter participant ID. Return to IP.3.0..
Response:

IP.8.0.
INTID Interviewer ID:

(Range: 001–999)
If number is less than 3 digits, then read, “Number must be three digits.” Return to IP 4.0..

Topic: Introduction (IN)
Response:

IN.1.0.

Text2 Intro_21_SURVEYIN “Thank you for taking part in this interview. Remember, your answers to these questions are
confidential. The answers to some questions may seem obvious, but I need to ask you all the
questions. There is a set of cards that we’ll use during the interview. The cards include a calendar,
pictures, and text to help you answer some of the questions. Please keep these cards nearby and I will
let you know when we need them.”
SURVEYIN

IP.7.2. – IN.1.0.

Page |19

Module: Eligibility criteria (Y)
Topic: MMP participation (YM)
YM.0.
Calculation_ST_INTN5 ST_INTN5 = Current time

Response:

YM.1.0.
PARTCPT Have you ever participated in the MMP interview?

No
0
1
Yes
8
Don't Know
7
Refused to answer
If YM.1.0. is 7 (refused to answer) then READ, “I’m only interviewing people who haven’t already been
interviewed during this data collection year. Thank you very much for your time.” Allow program to
move forward.
Skip_21_PARTCPT If YM.1.0. = 1 (yes), → YM.1.1.. If YM.1.0. = 0 (no) or 8 (don’t know), then → YS.1.0..
If YM.1.0. is 7 (refused to answer), → E.0..
Response:

YM.1.1.
PARTIC What month and year did you participate in the MMP interview?

Don't Know
8888
7777
Refused to answer
(Range: 06/2005-01/2050)
If CYGSN5_24 =2024 and YM.1.1. >= June 1, 2024 or if CYGSN5_24 =2025 and YM.1.1. >= June 1, 2025
or if CYGSN5_24 =2026 and YM.1.1. >= June 1, 2026 or if CYGSN5_24 =2027 and YM.1.1. >= June 1,
2027 or if CYGSN5_24 =2028 and YM.1.1. >= June 1, 2028, then read, “I’m only interviewing people
who haven’t already been interviewed during this data collection year. Thank you very much for your
time.” Allow program to move forward.
YM.1.1. cannot be later than IP.1.2.. If YM.1.1. > IP.1.2., then read, "Date cannot be later than
interview date." Do not allow program to advance.
Skip_24_PARTIC If CYGSN5_24 =2024 and YM.1.1. >= June 1, 2024 or if CYGSN5_24 =2025 and YM.1.1. >= June 1, 2025
or if CYGSN5_24 =2026 and YM.1.1. >= June 1, 2026 or if CYGSN5_24 =2027 and YM.1.1. >= June 1,
2027 or if CYGSN5_24 =2028 and YM.1.1. >= June 1, 2028, then → E.0.. If YM.1.1. is 7777 (refused to
answer), → E.0.. If YM.1.1. is 888 (don't know), then → YS.1.0.. Else, → YS.1.0..

YM.0. – YM.1.1.

Page |20

Topic: Residence (YS)
Response:

YS.1.0.

RESCURN8_21 What state or territory do you currently live in? [DON’T READ RESPONSES. SELECT ONLY ONE.]

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49

Alabama (AL)
Alaska (AK)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
District of Columbia (DC)
Florida (FL)
Georgia (GA)
Hawaii (HI)
Idaho (ID)
Illinois (IL)
Indiana (IN)
Iowa (IA)
Kansas (KS)
Kentucky (KY)
Louisiana (LA)
Maine (ME)
Maryland (MD)
Massachusetts (MA)
Michigan (MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)
Montana (MT)
Nebraska (NE)
Nevada (NV)
New Hampshire (NH)
New Jersey (NJ)
New Mexico (NM)
New York (NY)
North Carolina (NC)
North Dakota (ND)
Ohio (OH)
Oklahoma (OK)
Oregon (OR)
Pennsylvania (PA)
Puerto Rico (PR)
Rhode Island (RI)
South Carolina (SC)
South Dakota (SD)
Tennessee (TN)
Texas (TX)
Utah (UT)
Vermont (VT)
Virginia (VA)
Washington (WA)
YS.1.0. – YS.1.0.

Page |21

50
West Virginia (WV)
51
Wisconsin (WI)
52
Wyoming (WY)
53
Not living in the United States/Puerto Rico (ZZ)
88
Don't know
77
Refused to answer
If Current Residence= HI, ID, KS, KY, MO, MN, NE, or SD then read, “I am only interviewing people who
currently live in certain states. Thank you very much for your time.”
Skip_RESCURN8_21 If YS.1.0. is CA, IL, NY, PA, or TX, → YS.1.1.. If YS.1.0. is HI, ID, KS, KY, MO, MN, NE, or SD, → E.0.. If
YS.1.0. is 88 (don't know) or 77 (refused to answer) → RESAMPN8_24. Else, → RESAMPN8_24.
Response:

YS.1.1.

MMPCTYN5 What city do you currently live in? [DON’T READ RESPONSES. SELECT ONLY ONE.]

1
2
3
4
5
6
7
88
77

Chicago
Houston
Los Angeles County
New York City
Philadelphia
San Francisco
Other U.S. city
Don't Know
Refused to answer

YS.1.0. – YS.1.1.

Page |22
Response:

YS.2.0.

RESAMPN8_24 What state or territory did you live in on [Calculation_CLCSDT_24]? [DON’T READ RESPONSES.

SELECT ONLY ONE.]
1
Alabama (AL)
2
Alaska (AK)
3
Arizona (AZ)
4
Arkansas (AR)
5
California (CA)
6
Colorado (CO)
7
Connecticut (CT)
8
Delaware (DE)
9
District of Columbia (DC)
10
Florida (FL)
11
Georgia (GA)
12
Hawaii (HI)
13
Idaho (ID)
14
Illinois (IL)
15
Indiana (IN)
16
Iowa (IA)
17
Kansas (KS)
18
Kentucky (KY)
19
Louisiana (LA)
20
Maine (ME)
21
Maryland (MD)
22
Massachusetts (MA)
23
Michigan (MI)
24
Minnesota (MN)
25
Mississippi (MS)
26
Missouri (MO)
27
Montana (MT)
28
Nebraska (NE)
29
Nevada (NV)
30
New Hampshire (NH)
31
New Jersey (NJ)
32
New Mexico (NM)
33
New York (NY)
34
North Carolina (NC)
35
North Dakota (ND)
36
Ohio (OH)
37
Oklahoma (OK)
38
Oregon (OR)
39
Pennsylvania (PA)
40
Puerto Rico (PR)
41
Rhode Island (RI)
42
South Carolina (SC)
43
South Dakota (SD)
44
Tennessee (TN)
45
Texas (TX)
46
Utah (UT)
47
Vermont (VT)
48
Virginia (VA)
49
Washington (WA)
YS.2.0. – YS.2.0.

Page |23

50
51
52
53
88
77

West Virginia (WV)
Wisconsin (WI)
Wyoming (WY)
Not living in the United States/Puerto Rico (ZZ)
Don't know
Refused to answer

If RESAMPN8_24 (Residence on sampling date 24) is not CA, IL, NY, PA, TX, DE, FL, GA, IN, MI, MS, NJ,
NC, OR, PR, VA, or WA, then read, “I am only interviewing people who lived in certain states on
[INSERT Calculation_CLCSDT_24 (Sample date based on interview date 24)].Thank you very much for
your time.” Allow program to move forward.
Skip_21_RESAMPN8_24 If RESAMPN8_24 (Residence on sampling date 24) is CA, IL, NY, PA, or TX, → YS.2.1. (MMP city of
residence at sampling). If RESAMPN8_24 (Residence on sampling date 24) is DE, FL, GA, IN, MI, MS, NJ,
NC, OR, PR, VA, or WA, then → YA.1.0. (Date of birth). If RESAMPN8_24 (Residence on sampling date)
is 88 (don't know) or 77 (refused to answer), → E.0. (End of interview). Else → E.0. (End of interview).
Response:

YS.2.1.

SAMPCTN5 What city did you live in at that time? [DON’T READ RESPONSES. SELECT ONLY ONE.]

1
2
3
4
5
6
7
88
77

Chicago
Houston
Los Angeles County
New York City
Philadelphia
San Francisco
Other U.S. city
Don't Know
Refused to answer

Topic: Age (YA)
Response:

YA.1.0.
DOB_13 Please tell me the month and year of your date of birth.

8888
Don't Know
7777
Refused to answer
(Range: 01/1900-01/2050)
YA.1.0. cannot be later than IP.1.2.. If YA.1.0. > IP.1.2., then read, "Date cannot be later than interview
date." Do not allow program to advance.
Response:

YA.1.1.

Calculation_AGESMPN8_24 Calculate the difference in years between Calculation_CLCSDT_24 and DOB_13, accounting for leap years. Since
we do not gather day information for DOB_13, a day will need to be imputed: the last day of their birth month.

If Calculation_AGESMPN8_24 (Age at sampling date 24) is < 18 years, then READ, “I am only
interviewing people who were age 18 years or older on [INSERT Calculation_CLCSDT_24 (Sample date
based on interview date 24)]. Thank you very much for your time.” → E.0. (End of interview).
Skip_Calculation_AGESMP If YA.1.0. (Date of birth) is 7 (refused to answer) or 8 (don’t know), or if Calculation_AGESMPN8_24
N8_24 (Age at sampling date 24) is equal to 18 years, → AGEVER_24 (Age verifica^on 24). Else, → Y.0.1. (End
of eligibility section).
YA.1.2.
Calculation_AGEIDATE Calculate the respondent’s age at the time of the interview using DOB_13 (date of birth) and IDATE

(interview date).
YS.2.0. – YA.1.2.

Page |24
Response:

YA.1.3.
AGEVER_24 Were you at least 18 years old on [Calculation_CLCSDT_24]?

0
1
8
7

No
Yes
Don't Know
Refused to answer

If AGEVER_24 (Age verification 24) is 0 (no), 7 (refused to answer), or 8 (don’t know), then read, “I am
only interviewing people who were 18 years or older on [Calculation_CLCSDT_ 24 (Sample date based
on interview date 24)]. Thank you very much for your time.” Allow program to move forward.
Skip_21_AGEVER_24 If AGEVER_24 (Age verification 24) is 0 (no), 7 (refused to answer), or 8 (don’t know), then → E.0. (End
of interview). Else, → Y.0.1. (End of eligibility sec^on).
Y.0.1.
Calculation_EN_ELGN5 EN_ELGN5= Current time

YA.1.3. – Y.0.1.

Page |25

Module: Basic demographics (D)
Topic: Education (DE)
Response:

DE.1.0.

EDUC What is the highest level of education you completed? [READ RESPONSES. SELECT ONLY ONE.]

1
2
3
4
5
6
7
88
77

Never attended school
Grades 1 through 8
Grades 9 through 11
Grade 12 or GED
Some college, associate's degree, or technical degree
Bachelor's degree
Any post-graduate studies
Don't Know
Refused to answer

Topic: Race-ethnicity (DR)
Response:

DR.1.0.
HISPA_13 Do you consider yourself to be of Hispanic, Latino/a, or Spanish origin?

No
0
1
Yes
8
Don't Know
7
Refused to answer
Skip_HISPA_13 If DR.1.0. is 1 (yes), → Intro_HISN3A. Else, → Intro_RACE_9A.
Response:

DR.1.1.
Text2

Intro_HISN3A Which of the following describes your Hispanic, Latino/a, or Spanish origin? You can choose more than

one. [READ RESPONSES.]
HISN3A Mexican, Mexican American, or Chicano/a

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

DR.1.2.
HISN3B Puerto Rican

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

DR.1.3.
HISN3C Cuban

0
1
8
7

No
Yes
Don't Know
Refused to answer

DE.1.0. – DR.1.3.

Page |26
Response:

DR.1.4.
HISN3D Another Hispanic, Latino/a, or Spanish origin

No
0
1
Yes
8
Don't Know
7
Refused to answer
If DR.1.0. = 1 (Yes) and DR.1.1. = 0 (No) and DR.1.2. = 0 (No) and DR.1.3. = 0 (No) and DR.1.4. = 0 (No),
then read, “Earlier you said that you considered yourself to be of Hispanic, Latino/a, or Spanish origin.
I'll go back and read the choices again." Return to DR.1.0..
Response:

DR.2.1.
Text2

Intro_RACE_9A Which racial group or groups do you consider yourself to be in? You may choose more than one

option. [READ RESPONSES.]
RACE_9A American Indian or Alaska Native
0
No
1
Yes
8
Don't Know
7
Refused to answer
Response:

DR.2.2.
RACE_9B Asian

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

DR.2.3.
RACE_9C Black or African American

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

DR.2.4.
RACE_9D Native Hawaiian or Other Pacific Islander

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

DR.2.5.
RACE_9E White

0
No
1
Yes
8
Don't Know
7
Refused to answer
If DR.2.1. = 0 (No), DR.2.2. = 0 (No), DR.2.3. = 0 (No), DR.2.4. = 0 (No), and DR.2.5. = 0 (No), then
display, The respondent did not select any racial group. Please confirm responses. Allow the program
to move forward.

DR.1.4. – DR.2.5.

Page |27

Topic: Sex and sexual orientation (DG)
Response:

DG.1.0.
MFSEXN25

What is your sex: male or female? [DON'T READ RESPONSES.SELECT ONLY ONE]
1
2
8
7

DG.3.0.

SEXOR_N5 Do you think of yourself as [READ RESPONSES. SELECT ONLY ONE.]:

1
2
3
4
8
7

DG.3.1.

Male
Female
Don't Know
Refused to answer

Lesbian or gay
Straight, that is, not gay
Bisexual
Something else
Don't Know
Refused to answer

Skip_N24_SEXOR_N5

If DG.3.0. =4 (something else), → SEXOREXPN24. Else → DL.2.0..

SEXOREXPN24

What term do you use to describe yourself?

DG.1.0. – DG.3.1.

Page |28

Topic: Language ability (DL)
Response:

DL.1.0.
LANWL2N3 Do you speak a language other than English at home?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_24_LANWL2N3 If DL.2.0. is 1 (yes), → LANWL3N8_24. Else → DF.1.0..
Response:

DL.1.1.

LANWL3N8_24 What is this language? [DON’T READ RESPONSES. SELECT ALL THAT APPLY.]

1
American Sign Language
2
Amharic
3
Arabic
4
Chinese
5
French
6
German
7
Haitian Creole
8
Italian
9
Portuguese
10
Spanish
11
Swahili
12
Tagalog
13
Other
88
Don't know
77
Refused to answer
Skip_LANWL3N8_24 If LANWL3N8_24 =13 (Other), → LANN3OS_24. Else, → LANWL1N3_24.
Response:

DL.1.2.
LANN3OS_24 Specify language:

Response:

DL.2.0.
LANWL1N3_24 How well do you speak English? [READ RESPONSES. SELECT ONLY ONE.]

1
2
3
4
8
7

Very well
Well
Not well
Not at all
Don't know
Refused to answer

DL.1.0. – DL.2.0.

Page |29

Topic: U.S. born (DF)
Response:

DF.1.0.

COBORN_8 In what country or territory were you born? [DON'T READ RESPONSES. SELECT ONLY ONE.]

1
2
3
4
5
6
7
88
77

United States
Puerto Rico
Mexico
Haiti
Dominican Republic
Cuba
Other
Don't Know
Refused to answer
Response:

DF.1.1.
Skip_24_OTCTRY If DF.1.0. is 7 (other), → DF.1.1.. Else, → DJ.1.0..

OTCTRY Specify other country:

Topic: Incarceration (DJ)
DJ.1.0.

Response:
JAIL_N5 During the past 12 months, how many different times were you in jail, detention, or prison for

longer than 24 hours?
888
Don't Know
777
Refused to answer
(Range: 0-180)
If PRISONSETN24 = 01 and DJ.1.0. = 0, then read, Interviewer: the interview setting is a prison or jail
facility, but the respondent said they have not been incarcerated during the past 12 months. Please
clarify. Return to DJ.1.0..
Skip21_JAIL_N5 If DJ.1.0. is 0, 777 (refused to answer), or 888 (don’t know), then → Intro1_8_HOMEL_9A.
Else → DJ.1.1..
DJ.1.1.

Response:
DYINCN5 The last time you were in jail, detention, or prison for longer than 24 hours, how many days did you

spend in jail, detention, or prison?
8888
Don't Know
7777
Refused to answer
(Range: 1–7776)
If PRISONSETN24 = 0 and JAIL_N5 = 1, read the question as follows: How many days did you spend in
jail, detention, or prison?
If PRISONSETN24 = 1 (yes), read the question as follows: How many days have you currently spent in
jail, detention, or prison?
Skip_24_DYINCN5 If PRISONSETN24 (interviewed in prison or jail) = 1, then → Intro1_8_HOMEL_9A (Lived on the street).
If DJ.1.1. (Number of days when last incarcerated) is 8888 (don't know) or 7777 (refused to answer),
→ DJ.1.2. (Date of last release). Else → DJ.1.2. (Date of last release).

DF.1.0. – DJ.1.1.

Page |30
Response:

DJ.1.2.

DTINCN5 The last time you were in jail, detention, or prison for longer than 24 hours, what month and year

were you released?
8888
Don't Know
7777
Refused to answer
(Range: 01/1900-01/2050)
If JAIL_N5 = 1, read the question as follows: "What month and year were you released?"
DJ.1.2. cannot be earlier than IP.1.2. – 12 months. If DJ.1.2. is earlier than IP.1.2. – 12 months, then
read, “The release date has to be within the past 12 months. Please re-enter date.” Do not allow the
program to advance. If date is exactly 12 months prior to IP.1.2., then message should not pop up.
Allow program to advance.
DJ.1.2. cannot be later than IP.1.2.. If DJ.1.2. > IP.1.2., then read, “Date cannot be later than interview
date." Do not allow program to advance.

Topic: Homeless (DH)
Response:

DH.1.1.

Skip_N24_HOMEL_9A If PRISONSETN24 = 1, and DJ.1.1. ≥ 365, → A.0. (start ^me of disability). Else → Intro1_8_HOMEL_9A.
Text2
Text2Intro1_8_HOMEL_9A Next I’ll ask about the past 12 months. That is from last year [INSERT IP.1.2.-12 MONTHS] to today.
Text2Intro2_6_HOMEL_9A During the past 12 months,have you done any of the following:
HOMEL_9A …lived on the street?
0
No
1
Yes
8
Don't Know
7
Refused to answer

Response:

DH.1.2.
HOMEL_9B …lived in a shelter?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

DH.1.3.
HOMEL_9C …lived in a Single Room Occupancy (SRO) hotel?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

DH.1.4.
HOMEL_9D …lived in a car?

0
1
8
7

No
Yes
Don't Know
Refused to answer

DJ.1.2. – DH.1.4.

Page |31
Response:

DH.2.0.

DOUBLEN8 During the past 12 months, did you ever move in with other people even for a little while because

of financial problems?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Response:

DH.3.0.
MOVESN8 How many times have you moved during the past 12 months?

888
Don't Know
777
Refused to answer
(Range: 0-365)
Response:

DH.4.0.
EVICTN8 Have you been evicted at any time during the past 12 months?

0
1
8
7

No
Yes
Don't Know
Refused to answer

D.0.a.
Calculation_ENBSDMN5 ENBSDMN5 = Current time

DH.2.0. – D.0.a.

Page |33

Module: Disability (A)
Topic: Disability (AD)
Response:

AD.1.0.
Text2 Intro_21_DISDEFN3 “Now, I’m going to ask about conditions you may or may not have.”
DISDEFN3 Are you deaf or do you have serious difficulty hearing?
No
0
1
Yes
8
Don't Know
7
Refused to answer

Response:

AD.2.0.

DISBLNN3 Are you blind or do you have serious difficulty seeing, even when wearing glasses?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

AD.3.0.

DISCONN3 Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating,

remembering, or making decisions?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Response:

AD.4.0.
DISWLKN3 Do you have serious difficulty walking or climbing stairs?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

AD.5.0.
DISDRSN3 Do you have difficulty dressing or bathing?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

AD.6.0.

DISERRN3 Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone

such as visiting a doctor's office or shopping?
0
No
1
Yes
8
Don't Know
7
Refused to answer
A.0.a.
Calculation_ENDSABN5 ENDSABN5 = Current time

AD.1.0. – A.0.a.

Page |35

Module: Financial (F)
Topic: Employment (FE)
Response:

FE.1.0.

Text2 Intro_5_WORK_N3 “For the next question, please choose the answer that best describes your current employment
status. Tell me after I’ve read all the choices.”
WORK_N3 Are you currently…? [READ RESPONSES. SELECT ONLY ONE.]

1
2
3
4
5
6
7
8
88
77

Employed for wages
Self-employed
Out of work for more than 1 year
Out of work for less than 1 year
A homemaker
A student
Retired
Or unable to work
Don't know
Refused to answer

Topic: Income (FI)
Response:

FI.1.0.

Text2Intro_INCOME_8_21 “Now I’d like to ask you some questions about [INSERT I.5.0.]. That is from January 1st, [INSERT I.5.0.]
to December 31st, [INSERT I.5.0.]. For this next question, we will use Response Card A as well as the
calendar.”
INCOME_8_21 In [INSERT LASTYEAR], what was your combined monthly or yearly family income from all sources
before taxes? When I say “combined family income,” I mean the total amount of money from all
family members living in your household. Please tell me the letter that matches your income. [USE
RESPONSE CARD.]
1
a. $0 to $916 per month or $0 to $10,999 per year
2
b. $917 to $1,083 per month or $11,000 to $12,999 per year
3
c. $1,084 to $1,249 per month or $13,000 to $14,999 per year
4
d. $1,250 to $1,416 per month or $15,000 to $16,999 per year
5
e. $1,417 to $1,666 per month or $17,000 to $19,999 per year
6
f. $1,667 to $2,083 per month or $20,000 to $24,999 per year
7
g. $2,084 to $2,499 per month or $25,000 to $29,999 per year
8
h. $2,500 to $3,333 per month or $30,000 to $39,999 per year
9
i. $3,334 to $4,166 per month or $40,000 to $49,999 per year
10
j. $4,167 to $6,249 per month or $50,000 to $74,999 per year
11
k. $6,250 or more per month or $75,000 or more per year
88
Don't Know
77
Refused to answer
Skip_INCOME_8_21 If FI.1.0. is 77 (refused to answer) or 88 (don’t know), → FS.1.0.. Else, → FI.2.0..
Response:

FI.2.0.

DEPND_IN Including you, how many people depended on this income in [INSERT LASTYEAR]?

88
Don't Know
77
Refused to answer
(Range: 1–49)
Skip_DEPND_IN If FI.2.0. is greater than 1, → FI.2.1.. Else, → FS.1.0..

FE.1.0. – FI.2.0.

Page |36
Response:

FI.2.1.

DEPND_N3 Of the people who depended on this income in [INSERT LASTYEAR], how many were less than 18

years old?
88
Don't Know
77
Refused to answer
(Range: 0-48)
If FI.2.1. is greater than or equal to FI.2.0., read, "The number of people under 18 who depended on
your income in [INSERT I.5.0.] must be less than the total number of people who depended on your
income in [INSERT LAST YEAR]." Do not advance program.

Topic: Food security (FS)
Response:

FS.1.0.

FOOD3_N5 During the past 12 months, were you ever hungry but didn't eat because there wasn't enough

money for food?
0
No
1
Yes
8
Don't Know
7
Refused to answer

Topic: Healthcare coverage (FH)
Response:

FH.1.1.

Text2Intro_INSEMPN5_21 I’d like to ask you about health insurance and healthcare coverage you had during the past 12 months.
This is from [IP.1.2.-12 months] to today.
INSEMPN5_21 Did you have health insurance through your employer or a family member's employer?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Response:

FH.1.2.

INSMKTN5_21 Did you purchase health insurance through Healthcare.gov or the Health Insurance Marketplace?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

FH.1.3.

INSCOMPN21 Did you purchase a health insurance plan directly from a health insurance company?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

FH.1.4.
KINDB_5 Did you have Medicaid?

0
1
8
7

No
Yes
Don't Know
Refused to answer

FI.2.1. – FH.1.4.

Page |37
Response:

FH.1.5.
KINDC_5 Did you have Medicare?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

FH.1.6.

KINDD_5 Did you have coverage through Ryan White HIV/AIDS Program or AIDS Drug Assistance Program,

also called ADAP?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Response:

FH.1.7.

Skip_24_KINDEN21 If PRISONSETN24 = 1, and DJ.1.1. >= 365, → FH.1.8. (Insurance city/ county/st/other public). Else →

FH.1.7. (Insurance-military).
KINDEN21 Did you have military-based healthcare coverage, such as TRICARE, CHAMPUS, CHAMPVA, or

healthcare coverage through the Veterans Administration?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Response:

FH.1.8.

KINDG_5 Did you have city, county, state or other publicly funded insurance, not including Medicaid?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_24_ KINDG_5 If FH.1.7. (Insurance-military) is Skipped, treat as 0 (no). If FH.1.1. through FH.1.8. = 0 (no), → FH.1.9..
Else, → FH.2.0..
Response:

FH.1.9.
KINDJ_5 Did you have any other insurance?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_21_KINDJ_5 If FH.1.9. is 1 (yes), → FH.1.10.. If FH.1.9. is 0 (no), 7 (refused to answer) or 8 (don’t know), → Skip_21
_KINDOSN5.
Response:

FH.1.10.
KINDOSN5 Please tell me the other type of insurance that you had.

888
Don't Know
777
Refused to answer
Skip_21_KINDOSN5 If FH.1.7. is Skipped, treat as 0 (no). If FH.1.1. through FH.1.9. = 0 (no), → FH.1.9.. Else, → FH.2.0..

FH.1.5. – FH.1.10.

Page |38
Response:

FH.1.11.

KINDZN5_21 So, during the past 12 months, you had no health insurance and no other coverage for any type of

healthcare including help with payment for your medications. Is that correct?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_KINDZN5_21 If FH.1.9. = 0 (no), then return to FH.1.1.. Ask this section again. If FH.1.9. = 1 (yes), 7 (refused to
answer), or 8 (don't know), → FH.3.0..
Response:

FH.2.0.

INS12_9_21 During the past 12 months, was there a time that you didn’t have any health insurance or

healthcare coverage?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_INS12_9_21 If FH.2.0. is 1 (yes), → FH.2.1. .
If FH.2.0. is 0 (no), 7 (refused to answer) or 8 (don't know), → FH.3.0..
Response:

FH.2.1.

INSMTHN5_21 During the past 12 months, about how many months were you without health insurance or other

healthcare coverage? If it is less than one month, round up to "1 month."
88
Don't Know
77
Refused to answer
(Range: 1-12)
Response:

FH.3.0.

PAY_N5 During the past 12 months, did you have problems paying or were you unable to pay any medical

bills for your own care?
0
No
1
Yes
8
Don't Know
7
Refused to answer
F.0.a.
Calculation_ENFINAN5 ENFINAN5= Current time

FH.1.11. – F.0.a.

Page |39

Module: General medical care (J)
Topic: Health and well-being (JW)
Response:

JW.1.0.
INTRO_21_GENHLTHN8 "Now I'm going to ask about your health."
Text2
GENHLTN8 In general, is your health [READ RESPONSES. SELECT ONLY ONE.]:
Poor
1
2
Fair
3
Good
4
Very good
5
Excellent
8
Don't know
7
Refused to answer

Topic: ER and hospitalizations (JH)
Response:

JH.1.0.

HOSPERN5 During the past 12 months, how many times have you gone to a hospital emergency room about

your own health? This includes emergency room visits that resulted in a hospital admission.
Don't Know
888
777
Refused to answer
(Range: 0–776)
Response:

JH.2.0.

HOSPONN5 During the past 12 months, were you a patient in a hospital overnight? Don’t include an overnight

stay in the emergency room.
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_HOSPONN5_8 If JH.2.0. = 0 (no), 7 (refused to answer), or 8 (don’t know), then → JF.1.0.. Else, → JH.2.1..
Response:

JH.2.1.

NUMONN5 During the past 12 months, how many different times did you stay in any hospital overnight or

longer?
888
Don't Know
777
Refused to answer
(Range: 1-365)

Topic: Influenza (JF)
Response:

JF.1.0.
VACFL_8 During the past 12 months, did you get a flu shot?

0
1
8
7

No
Yes
Don't know
Refused to answer

JW.1.0. – JF.1.0.

Page |40

Topic: Health literacy (JL)
JL.1.0.

Response:

Text2 Intro_8_HLMF_12 For the next question, we'll use Response Card B.
HLMF_12 How confident are you filling out medical forms by yourself? [USE RESPONSE CARD. SELECT ONLY
ONE.]
1
Extremely
2
Quite a bit
3
Somewhat
4
A little bit
5
Not at all
8
Don't Know
7
Refused to answer
Skip_8_HLMF_12 → J.0.a..
J.0.a.
Calculation_ENGNMDN5 ENGNMDN5 = Current time

JL.1.0. – J.0.a.

Page |41

Module: HIV care (K)
Topic: Diagnosis date (KD)
K.0.
Calculation_STHVCAN5 STHVCAN5 = Current time

KD.1.0.

Response:

Text2Intro_N21_IPERINN3 Next, I'm going to ask some questions about HIV.
IPERINN3 Were you born with HIV?
No
0
1
Yes
8
Don't Know
7
Refused to answer
If KD.1.0. is 1 (yes) and YA.1.0. is earlier than January 1977, read, “The date of birth provided is earlier
than 1977, the date of the first persons born with HIV were documented. Confirm date of birth.”
Allow program to move forward.
Skip_21_IPERINN3 If KD.1.0. = 1, then → Intro_21_EVERCR_8. KD.1.0. = 0 (no), 8 (don't know) or 7 (refused to answer),
→ KD.2.0..
KD.2.0.

Response:
POS1S_9 What month and year did you first test positive for HIV? Tell me when you got your result, not when

you got your test.
Don't Know
8888
7777
Refused to answer
(Range: 01/1900-01/2050)
If KD.2.0. is earlier than March 1985, confirm response. If KD.2.0. is earlier than 03/1985, read, “The
date entered is earlier than 03/1985, the date of the first FDA-approved HIV test. Confirm date of HIV
test.” Program should move forward regardless of date.
KD.2.0. cannot be earlier than YA.1.0.. If KD.2.0. is earlier than YA.1.0., then read, “Date first tested
positive cannot be earlier than date of birth.”
KD.2.0. cannot be later than IP.1.2.. If KD.2.0. > IP.1.2., then read, “Date cannot be later than interview
date." Do not allow program to advance.

K.0. – KD.2.0.

Page |42

Topic: Ever care (KE)
Response:

KE.1.0.

Text2 Intro_21_EVERCR_8 Next, I’ll ask about HIV care. By that, I mean routine care from a doctor, nurse, or other healthcare
worker to treat HIV—not emergency care when you go to an urgent care center, emergency room, or
stay in a hospital overnight.
EVERCR_8 Since testing positive for HIV in _ _ /_ _ _ _ [INSERT POS1S_9 (date first tested positive for HIV)],
have you ever seen a doctor, nurse, or other healthcare worker for HIV care?
0
No
1
Yes
8
Don't Know
7
Refused to answer
If POS1S_9 has an unknown month value but a known year value, then read: Since testing positive for
HIV in [Insert year from POS1S_9], have you ever seen a doctor, nurse, or other healthcare worker for
HIV care? If POS1S_9 is 77/7777 (refused to answer), 88/8888 (don’t know) or Skipped, then EVERCR_
8 should read as follows: Since testing positive for HIV, have you ever seen a doctor, nurse, or other
healthcare worker for HIV care? If IPERINN3 = 1 (yes), then read: Have you ever seen a doctor, nurse,
or other healthcare worker for HIV care?
If KE.1.0. = 0, then read "Are you sure that you have never received HIV care?" Allow the program to
move forward.
Skip_EVERCR_8 If KD.1.0. = 1, then → Skip_MSAPPT_8. Else, → Skip_CARE1_8.

Topic: Linkage to care (KL)
Response:

KL.1.0.
Skip_CARE1_8 If KD.2.0. < 5 years from IP.1.2., → Skip2_CARE1_8.

If KD.2.0.>= 5 years from IP.1.2. or if KD.2.0. is 88/8888 (don't know), 77/7777 (refused to answer), or
skipped, → Skip_MSAPPT_8.
Skip2_CARE1_8 If KE.1.0. is 0 (no), 7 (refused to answer), or 8 (don't know), → Intro_PREF1_8.

CARE1_8 Within 30 days after testing positive, did you see a doctor, nurse, or other healthcare worker for HIV

care?
0
1
8
7
KL.2.0.
Text2

No
Yes
Don't Know
Refused to answer
Response:

Intro_PREF1_8 Next I’ll ask whether you got help getting connected to HIV care from a professional. A professional

could be someone like a doctor, nurse, social worker, patient navigator, or receptionist. If you don’t
remember, it’s okay to answer "don’t know."
PREF1_8 Within 30 days after testing positive, did a professional ask if you needed help finding a place to go
for HIV care?
0
No
1
Yes
8
Don't Know
7
Refused to answer

KE.1.0. – KL.2.0.

Page |43
Response:

KL.3.0.

PREF2N8 Within 30 days after testing positive, did a professional tell you where you could go for HIV care?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

KL.4.0.

AREF4_8 Within 30 days after testing positive, did a professional help you figure out if you qualified for free

or low-cost HIV care?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Response:

KL.5.0.

AREF1_8 Within 30 days after testing positive, did a professional make an appointment for you to receive HIV

care?
0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

KL.6.0.

AREF2_8 Within 30 days after testing positive, did a professional arrange transportation for you to an HIV

care appointment?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Response:

KL.7.0.

AREF5N8 Within 30 days after testing positive, did anyone contact you to remind you of your first HIV care

appointment?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Response:

KL.8.0.

Skip_AREF3_8 If KL.1.0. = 0 (no), 7 (refused), or 8 (don't know), then → Skip_MSAPPT_8. If KE.1.0. = 0 (no), 7

(refused), or 8 (don't know), then → Skip_MSAPPT_8. Else, → KL.8.0..
AREF3_8 Within 30 days after testing positive, did a professional go with you to your first HIV care

appointment?
0
No
1
Yes
8
Don't Know
7
Refused to answer

KL.3.0. – KL.8.0.

Page |44

Topic: Care utilization (KU)
Response:

KU.1.0.
Skip_ MSAPPT_8 If KE.1.0. = 1 (yes), → KU.1.0..

If KE.1.0. = 0 (no), 7 (refused to answer), or 8 (don't know), → Intro_21_BARRI1N8.
MSAPPT_8 During the past 12 months, have you missed any scheduled appointments for HIV care that you

didn’t cancel? Don't include appointments that were cancelled by the clinic.
0
No
1
Yes
8
Don't Know
7
Refused to answer
If POS1S_9 is less than 12 months from IDATE, then display the text as follows: “Have you missed any
scheduled appointments for HIV care that you didn’t cancel? Don’t include appointments that were
canceled by the clinic.”
KU.2.0.

Response:
LASCA_8 What month and year was your most recent visit to a doctor, nurse, or other healthcare worker for

HIV care?
8888
Don't Know
7777
Refused to answer
(Range: 01/1900-01/2050)
KU.2.0. cannot be earlier than YA.1.0.. If KU.2.0. < YA.1.0., then read, "Date cannot be earlier than
date of birth." Do not allow program to advance.
KU.2.0. cannot be earlier than KD.2.0.. If KU.2.0. < KD.2.0., then read, "Your most recent care visit
cannot be earlier than your diagnosis date." Do not allow program to advance.
KU.2.0. cannot be later than IP.1.2.. If KU.2.0. > IP.1.2., then read, "Date cannot be later than interview
date." Do not allow program to advance.
Skip_24_LASCA_8 If KU.2.0. is 2 years or more before IP.1.2., then → HCPROVN8_24. Else, → KU.3.0..
KU.3.0.

Response:
USOCN5_8 During the past 2 years, what is the name of the place you went for most of your HIV care?

If POS1S_9 is less than 24 months from IDATE, then display the text as follows: “What is the name of
the place you went for most of your HIV care?”
KU.4.0.

Response:
NYMLTF_21 During the past 2 years, have you seen a doctor, nurse, or other healthcare worker for HIV care at

any facility besides [INSERT NAME OF PLACE YOU WENT FOR MOST OF YOUR CARE]?
0
No
1
Yes
8
Don't Know
7
Refused to answer
If POS1S_9 is less than 24 months from IDATE, then display the text as follows: “Have you seen a
doctor, nurse, or other healthcare worker for HIV care at any facility besides [INSERT NAME OF PLACE
YOU WENT FOR MOST OF YOUR CARE]?”
Skip_24_NYMLTF_21 If KU.4.0. = 0 (no), 7 (refused to answer), or 8 (don't know), then → HCPROVN8_24. Else, → KU.4.1..

KU.1.0. – KU.4.0.

Page |45
Response:

KU.4.1.

MLTFA2_8 During the past 2 years, at how many total facilities have you received HIV care? Please include

[INSERT NAME OF PLACE YOU WENT FOR MOST OF YOUR CARE] in the total.
888
Don't Know
777
Refused to answer
(Range: 2-99)
If POS1S_9 is less than 24 months from IDATE, then display the text as follows: “At how many total
facilities have you received HIV care? Please include [INSERT NAME OF PLACE YOU WENT FOR MOST
OF YOUR CARE] in the total.”

Topic: Patient-provider relationship (KB)
Response:

KB.1.0.

HCPROVN8_24 Do you have a doctor, nurse, or other health care worker whom you see for most of your HIV care?

0
1
8
7
Skip_HCPROVN8_24

No
Yes
Don't Know
Refused to answer

If HCPROVN8_24 = 0 (no), 7 (refused to answer), or 8 (don’t know), → Intro_21_BARRI1N8. Else, →
Intro_commu1n24.
Response:

KB.2.0.

Text2Intro_COMMU1N24 The next two questions are about the doctor, nurse, or other health care worker you see for most of
your HIV care.
COMMU1N24 How often do they take the time to listen to you? [READ RESPONSES. SELECT ONLY ONE.]
1
Never
2
Rarely
3
Sometimes
4
Usually
5
Always
8
Don't Know
7
Refused to answer
Response:

KB.3.0.

COMMU2N24 How often do they involve you in decisions about your health? [READ RESPONSES. SELECT ONLY

ONE.]
1
2
3
4
5
8
7

Never
Rarely
Sometimes
Usually
Always
Don't Know
Refused to answer

KU.4.1. – KB.3.0.

Page |46

Topic: Barriers and facilitators to care (KP)
KP.1.0.

Response:

Text2 Intro_21_BARRI1N8 "I want to ask you about things that either get in the way or help people get HIV care."
BARRI1N8 During the past 12 months, have problems with money or health insurance made it difficult for you
to get HIV care?
0
No
1
Yes
8
Don't Know
7
Refused to answer
If POS1S_9 is less than 12 months from IDATE, then display the text as follows: “Have problems with
money or health insurance made it difficult for you to get HIV care?”
KP.2.0.

Response:
BARRI2N8 During the past 12 months, has depression or mental health problems made it difficult for you to

get HIV care?
0
No
1
Yes
8
Don't Know
7
Refused to answer
If POS1S_9 is less than 12 months from IDATE, then display the text as follows: “Has depression or
mental health problems made it difficult for you to get HIV care?”
KP.3.0.

Response:
BARRI3N8 During the past 12 months, have you delayed getting HIV care because you felt well?

0
No
1
Yes
8
Don't Know
7
Refused to answer
If POS1S_9 is less than 12 months from IDATE, then display the text as follows: “Have you delayed
getting HIV care because you felt well?”
KP.4.0.

Response:
BARRI4N8 During the past 12 months, have you had trouble getting HIV care because a doctor's office or HIV

clinic was hard to get to?
0
No
1
Yes
8
Don't Know
7
Refused to answer
If POS1S_9 is less than 12 months from IDATE, then display the text as follows: “Have you had trouble
getting HIV care because a doctor's office or HIV clinic was hard to get to?”
KP.5.0.

Response:
BARRI5N8 During the past 12 months, have you delayed getting HIV care because you were too busy with

other personal things, such as family or work?
0
No
1
Yes
8
Don't Know
7
Refused to answer
If POS1S_9 is less than 12 months from IDATE, then display the text as follows: “Have you delayed
getting HIV care because you were too busy with other personal things, such as family or work?”
KP.1.0. – KP.5.0.

Page |47

Module: HIV treatment and adherence (T)
Topic: Ever ART (TE)
Response:

TE.1.0.

Text2 Skip_21_EART_N5 If KE.1.0. is 1 (yes), → Intro_21_EART_N5.
Else if KE.1.0. is 0 (No) or 8 (Don't Know) or 7 (Refused to Answer), → T.0.a..
Text2 Intro_21_EART_N5 “Now I’m going to ask about medicines that you may be taking for HIV. These HIV medicines are also
known as antiretroviral medicines or ART. The questions are about HIV medicines taken after you
tested positive for HIV.”
EART_N5 Have you ever taken any HIV medicines?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip2_21_EART_N5 If TE.1.0. is 1 (yes), → Skip_N21_FART_N5. If TE.1.0. is 7 (refused to answer) or 8 (don’t know), →
T.0.a.. Else if TE.1.0. is 0 (No) go Intro_8_NART1_N5.
Response:

TE.1.1.

Text2 Intro_8_NART1_N5 “I’m going to read you a list of reasons why some people have not taken HIV medicines after testing
positive for HIV. For each reason, please tell me 'yes' or 'no' if it applies to your situation.”
NART1_N5 No healthcare provider has ever talked to you about taking HIV medicines.
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_8_NART1_N5 If TE.1.1. = 1 (yes) then → TE.1.3.. Else, → TE.1.2..
Response:

TE.1.2.
NART2_N5 Your doctor said you should not start taking HIV medicines.

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

TE.1.3.

NART3_N5 You have problems paying for or getting insurance or coverage for HIV medicines.

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

TE.1.4.

NART4_N5 You decided not to take HIV medicines because you don’t think you need them.

0
1
8
7

No
Yes
Don't Know
Refused to answer

TE.1.0. – TE.1.4.

Page |48
Response:

TE.1.5.

NART5_N5 You decided not to take HIV medicines because you think they would make you feel sick or harm

you.
0
1
8
7
Skip_N21_NART5_N5 → T.0.a..

No
Yes
Don't Know
Refused to answer

Response:

TE.2.0.

Skip_N21_FART_N5 If KD.2.0. is greater than 5 years from IP.1.2., → TC.1.0.. If KD.2.0. is 7777 (refused to answer) Or 8888

(don't know) or missing, then → TC.1.0.. If KD.1.0. = 1, then → TC.1.0.. If POS1S-9 is REF, DK, or missing,
then skip o TC.1.0.. Else If POS1S_9M is missing and (POS1S_9Y = 5 years from IP.1.2. or POS1S_9Y is
less than 5 years from IP.1.2.) → TE.2.0.. If KD.2.0. = 5 years from IP.1.2. or KD.2.0. is less than 5 years
from IP.1.2. → TE.2.0..
FART_N5 When was the first time you ever took any HIV medicines? Please tell me the month and year.

8888
Don't Know
7777
Refused to answer
(Range: 01/1900-01/2050)
TE.2.0. cannot be earlier than KD.2.0.. If TE.2.0. was before KD.2.0., then read, “The date first took HIV
medications cannot be earlier than the HIV diagnosis date. Please re-enter date." Do not allow the
program to advance.
TE.2.0. cannot be earlier than YA.1.0.. If TE.2.0. was before YA.1.0., then read, “The date first took HIV
medications cannot be earlier than the date of birth. Please re-enter date." Do not allow the program
to advance.
TE.2.0. cannot be later than IP.1.2.. If TE.2.0. > IP.1.2., then read, "Date cannot be later than interview
date." Do not allow program to advance.

Topic: Current ART (TC)
Response:

TC.1.0.
CART_N5 Are you currently taking any HIV medicines?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_N24_CART_N5 If TC.1.0. is 1 (yes), → Intro_ARTTYP1N24. Else, → TC.2.0..
Response:

TC.2.0.
ATMD12_9 During the past 12 months, have you taken HIV medicines?

0
No
1
Yes
8
Don't Know
7
Refused to answer
If POS1S_9 is less than 12 months from IDATE, then display the text as follows: Since being diagnosed
with HIV, have you taken HIV medicines?
Skip_24_ATMD12_9 If TC.1.0. is 1 (yes), 7 (refused to answer) or 8 (don't know), then → Intro_ARTTYP1N24. If TC.1.0. is 0
(no), → Intro_8_CART1_N5.

TE.1.5. – TC.2.0.

Page |49
Response:

TC.2.1.

Text2 Intro_8_CART1_N5 “I’m going to read you a list of reasons why some people are not currently taking HIV medicines. For
each reason, please tell me 'yes' or 'no' if it applies to your situation.”
CART1_N5 No healthcare provider has talked to you about restarting HIV medicines.
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_8_CART1_N5 If TC.2.1. = 1 (yes) then → TC.2.3.. Else, → TC.2.2..
Response:

TC.2.2.
CART2_N5 Your doctor said you should not take HIV medicines.

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

TC.2.3.

CART3_N5 You have problems paying for or getting insurance or coverage for HIV medicines.

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

TC.2.4.

CART4_N5 You decided not to take HIV medicines because you don’t think you need them.

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

TC.2.5.

CART5_N5 You decided not to take HIV medicines because you think they would make you feel sick or harm

you.
0
1
8
7
Skip_N24_CART5_N5 → T.0.a..

No
Yes
Don't Know
Refused to answer

Topic: Adherence (TA)
TA.1.0.

Response:

Text2 Intro_ARTTYP1N24 People can take HIV medicines in different forms. Are any of your current HIV medicines…
ARTTYP1N24 Pills?
0
No
1
Yes
8
Don't Know
7
Refused to answer

TC.2.1. – TA.1.0.

Page |50
Response:

TA.1.1.
ARTTYP2N24 IV infusions?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

TA.1.2.
ARTTYP3N24 Shots?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

TA.1.3.
ARTTYP4N24 Implants?

0
No
1
Yes
8
Don't Know
7
Refused to answer
If ARTTYP1N24 (Pills) =0 (no) and ARTTYP2N24 (IV infusions)=0 (no) and ARTTYP3N24 (shots)=0 (no)
and ARTTYP4N24 (implants)=0 (no), then read" Earlier you told me that you are currently taking HIV
medication. Is this correct?" Interview instructions: Return to previous question TC.1.0. to correct
error.
Response:

TA.1.4a.

SKIP_N24_ARTTYP5N24 If (ARTTYP1N24=0, 7, or 8) and (ARTTYP2N24=0, 7 or 8) and (ARTTYP3N24=0, 7 or 8) and (ARTTYP4N24

=0, 7 or 8), → T.0.a. (End of HIV treatment and adherence)
ARTTYP5N24 We realize it can be hard for people to take all their medications exactly as they are

supposed to.
1. Continue
TA.1.4.

Response:

Skip_N24_ADH1N5_24 IF ARTTYP1N24 = 1 (yes), then → Intro1_24_ADH1N5_24. Else → Skip_IVADH1N24.
Text2
Intro1_24_ADH1N5_24 Now I am going to ask you about your HIV medicines that are pills. I’m going to ask you about the past
Text2
30 days. That is from [INSERT IP.1.2. - 30 DAYS] to today. [SHOW RESPONDENT CALENDAR]
ADH1N5_24 During the past 30 days, on how many days did you miss at least one dose of any of your HIV pills?
88
Don't know
77
Refused to answer

TA.1.1. – TA.1.4.

Page |51
Response:

TA.1.5

ADH2N5_24 During the past 30 days, how good a job did you do at taking your HIV pills in the way you were

supposed to? [READ RESPONSES. SELECT ONLY ONE].
1
Very poor
2
Poor
3
Fair
4
Good
5
Very good
6
Excellent
8
Don't know
7
Refused to answer
Response:

TA.1.6

ADH3N5_24 During the past 30 days, how often did you take your HIV pills in the way you were supposed to?

[READ RESPONSES. SELECT ONLY ONE.]
1
Never
2
Rarely
3
Sometimes
4
Usually
5
Almost always
6
Always
8
Don't know
7
Refused to answer
TA.1.7.

Response:

Text2 Skip_IVADH1N24 If ARTTYP2N24 (IV infusions)=1 (yes) → Intro_IVADH1N24. Else → Skip_INJADH1N24.
Text2 Intro_IVADH1N24 Now I am going to ask you about your HIV medicines that are IV infusions.
IVADH1N24 During the past 12 months, did you miss an IV infusion?
No
0
1
Yes
8
Don't Know
7
Refused to answer
If POS1S_9 is less than 12 months from IDATE, then display the text as follows: “Did you miss an IV
infusion?"
TA.1.8.

Response:
IVADH2N24 During the past 12 months, how good a job did you do at getting your IV infusions in the way you

were supposed to? [READ RESPONSES. SELECT ONLY ONE].
1
Very poor
2
Poor
3
Fair
4
Good
5
Very good
6
Excellent
8
Don't Know
7
Refused to answer
If POS1S_9 is less than 12 months from IDATE, then display the text as follows: “How good a job did
you do at getting your IV infusions in the way you were supposed to? [READ RESPONSES. SELECT
ONLY ONE]"

TA.1.5 – TA.1.8.

Page |52
Response:

TA.1.9.

IVADH3N24 During the past 12 months, how often did you get your IV infusions in the way you were supposed

to? [READ RESPONSES. SELECT ONLY ONE.]
1
Never
2
Rarely
3
Sometimes
4
Usually
5
Almost always
6
Always
8
Don't Know
7
Refused to answer
If POS1S_9 is less than 12 months from IDATE, then display the text as follows: How often did you get
your infusions in the way you were supposed to? [READ RESPONSES. SELECT ONLY ONE.]
TA.1.10.

Response:

Text2 Skip_INJADH1N24 If ARTTYP3N24 (shots) = 1 (yes), → Intro_INJADH1N24. Else → Skip_IMPADH1N24.
Text2 Intro_INJADH1N24 Now I am going to ask you about your HIV medicines that are shots.
INJADH1N24 During the past 12 months, did you miss a shot?
0
No
1
Yes
8
Don't Know
7
Refused to answer
If POS1S_9 is less than 12 months from IDATE, then display the text as follows: "Did you miss a shot?"
TA.1.11.

Response:
INJADH2N24 During the past 12 months, how good a job did you do at getting your shots in the way you were

supposed to? [READ RESPONSES. SELECT ONLY ONE.]
1
Very poor
2
Poor
3
Fair
4
Good
5
Very good
6
Excellent
8
Don't Know
7
Refused to answer
If POS1S_9 is less than 12 months from IDATE, then display the text as follows: "How good a job did
you do at getting your shots in the way you were supposed to? [READ RESPONSES. SELECT ONLY
ONE.]"

TA.1.9. – TA.1.11.

Page |53
TA.1.12.

Response:
INJADH3N24 During the past 12 months, how often did you get your shots when you were supposed to? [READ

RESPONSES. SELECT ONLY ONE.]
1
Never
2
Rarely
3
Sometimes
4
Usually
5
Almost always
6
Always
8
Don't Know
7
Refused to answer
If POS1S_9 is less than 12 months from IDATE, then display the text as follows: "How often did you get
your shots when you were supposed to? [READ RESPONSES. SELECT ONLY ONE.]"
TA.1.13.

Response:

Text2 Skip_IMPADH1N24 If ARTTYP4N24 (implant) = yes, → Intro_IMPADH1N24. Else → TA.2.0..
Text2 Intro_IMPADH1N24 Now I am going to ask you about your HIV medicine that is an implant.
IMPADH1N24 During the past 12 months, did you miss an implant?
0
No
1
Yes
8
Don't Know
7
Refused to answer
If POS1S_9 is less than 12 months from IDATE, then display the text as follows: "Did you miss an
implant?"
TA.1.14.

Response:
IMPADH2N24 During the past 12 months, how good a job did you do at getting your implant in the way you were

supposed to? [READ RESPONSES. SELECT ONLY ONE.]
1
Very poor
2
Poor
3
Fair
4
Good
5
Very good
6
Excellent
8
Don't Know
7
Refused to answer
If POS1S_9 is less than 12 months from IDATE, then display the text as follows: "How good a job did
you do at getting your implant in the way you were supposed to? [READ RESPONSES. SELECT ONLY
ONE.]"

TA.1.12. – TA.1.14.

Page |54
Response:

TA.1.15.

IMPADH3N24 During the past 12 months, how often did you get your implant when you were supposed to? [READ

RESPONSES. SELECT ONLY ONE.]
1
Never
2
Rarely
3
Sometimes
4
Usually
5
Almost always
6
Always
8
Don't Know
7
Refused to answer
If POS1S_9 is less than 12 months from IDATE, then display the text as follows: "How how often did
you get your implant when you were supposed to? [READ RESPONSES. SELECT ONLY ONE.]"
Response:

TA.2.0.

TRBL_EFT For the next question we will use Response Card D. During the past 30 days, how often were you

troubled by side effects from any of your HIV medicines? [USE RESPONSE CARD. SELECT ONLY ONE.]
1
Never
2
Rarely
3
About half of the time
4
Most of the time
5
Always
8
Don't know
7
Refused to answer
Response:

TA.3.0.

Text2Skip_N24_MIS1N5_8 If ADH1N5_24 (days missed taking ART) >=1 or IVADH1N24 (missed ART infusion)=1 or INJADH1N24
(missed ART injection)=1 or IMPADH1N24 (missed ART implant) =1, → Intro_MIS1N5_8. Else → T.0.a..
Text2 Intro_MIS1N5_8 “The last time you missed taking your HIV medicines, which of the following were reasons you
missed? Please answer 'yes' or 'no' to each reason.”
MIS1N5_8 You had a problem paying for your HIV medicines.
0
No
1
Yes
8
Don't Know
7
Refused to answer
Response:

TA.3.1.
MIS2_N5 You were in the hospital or too sick to take your HIV medicines.

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

TA.3.2.
MIS3_N5 You fell asleep early or overslept.

0
1
8
7

No
Yes
Don't Know
Refused to answer

TA.1.15. – TA.3.2.

Page |55
Response:

TA.3.3.
MIS4_N5 You had a change in your daily routine or were out of town.

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

TA.3.4.
MIS5_N5 You had side effects from your HIV medicines.

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

TA.3.5.
MIS6_N5 You felt depressed or overwhelmed.

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

TA.3.6.
MIS7_N5 You were drinking or using drugs.

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

TA.3.7.
MIS8_N5 You forgot to take your HIV medicines.

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

TA.3.8.
MIS9_N5 You did not feel like taking your HIV medicines.

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

TA.3.9.

MIS10_N8 You had a problem getting a prescription or a refill for your HIV medicines.

0
1
8
7

No
Yes
Don't Know
Refused to answer

TA.3.3. – TA.3.9.

Page |57

Module: Emotional social support (V)
Topic: Emotional social support (VS)
V.0.
Calculation_STSUPPORTN24 STSUPPORTN24 = Current time

Response:

VS.1.0.

Text2Intro_SUPPORT1N24 The next four statements are about social support. Tell me how often you feel this way.
SUPPORT1N24 I have someone who will listen to me when I need to talk. [READ RESPONSES. SELECT ONLY ONE.]
1
Never
2
Rarely
3
Sometimes
4
Usually
5
Always
8
Don't know
7
Refused to answer
Response:

VS.2.0.

SUPPORT2N24 I have someone to confide in or talk to about myself or my problems. [READ RESPONSES. SELECT

ONLY ONE.]
1
2
3
4
5
8
7

Never
Rarely
Sometimes
Usually
Always
Don't know
Refused to answer
Response:

VS.3.0.

SUPPORT3N24 I have someone who makes me feel appreciated. [READ RESPONSES. SELECT ONLY ONE.]

1
2
3
4
5
8
7

Never
Rarely
Sometimes
Usually
Always
Don't know
Refused to answer
Response:

VS.4.0.

SUPPORT4N24 I have someone to talk with when I have a bad day. [READ RESPONSES. SELECT ONLY ONE.]

1
2
3
4
5
8
7

Never
Rarely
Sometimes
Usually
Always
Don't know
Refused to answer

V.0.a.
Calculation_ENDSUPPORTN2 ENDSUPPORTN24 = Current time
4

V.0. – V.0.a.

Page |59

Module: Sexual behavior (S)
Topic: Total sex partners (ST)
ST.1.0.
Calculation_SX_25

If MFSEXN25 =Male then SX_25=1 (Male). If
MFSEXN25=Female then SX_25=2 (Female).
1
2

Skip_N21_SX_25

Male
Female

If ST.1.0. = 3, → Intro2_N21_SX_TFPN4. Else, → Intro1_ N21_SX_TFPN4.

Response:

ST.2.0.

Intro1_N21_SX_TFPN4 "Next I'm going to ask you about sex. When I say sex, I mean vaginal or anal sex. Vaginal sex means
Text2
penis in the vagina and anal sex means penis in the anus. When answering, don't include people you
only had oral sex with. The number of people could range anywhere from 0 to over a hundred.
Remember that your answers will be private."
Text2 Skip1_SX_TFPN4 All responses → Skip2_SX_TFPN4.

Skip2_SX_TFPN4 If ST.1.0.=2 (Female), → ST.3.0.. Else, → ST.2.0..

SX_TFPN4 During the past 12 months, how many females have you had sex with?

8888
Don't know
7777
Refused to answer
(Range: 0-999)
Response:

ST.3.0.
SX_TMPN4 During the past 12 months, how many males have you had sex with?

8888
Don't know
7777
Refused to answer
(Range: 0-999)
Response:

ST.1.0. – ST.4.0.

Page |60
ST.5.0.
Calculation_SX_TOTN4 Create a calculated variable where the sum of SX_TFPN4 + SX_TMPN4 = SX_TOTN4

(total number of sex partners).
If the response to SX_TFPN4 (number of female partners) and SX_TMPN4 (number of male partners)
is 7 (refused to answer) or 8 (don’t know), then calculate the response as “0.” EXAMPLE: if
SX_TFPN4 = 8 (don’t know) AND SX_TMPN4 = 8 (don’t know) THEN SX_TOTN4 = 0.
If any of the values are Skipped (.S), then do not include the value in the calculation. EXAMPLE: if
SX_TFPN4 = 2 AND SX_TMPN4 = 8 (don’t know) then SX_TOTN4 (total number of sex partners) = 2.

Female only partners: create a calculated variable SXFMONN4 (female only partners) if SX_TMPN4
(number of male partners) = 0, 8 (don’t know), or 7 (refused to answer) AND SX_TFPN4 (number of
Calculation_SXFMONN4 female partners) >= 1, then SXFMONN4 (female only partners) = 1; else SXFMONN4 = 0.

ST.6.0.

Male only partners: create a calculated variable SXMLONN4 (male only partners) if SX_TFPN4
(number of female partners) = 0, 8 (don’t know), or 7 (refused to answer) or .S (skipped) AND
ST.7.0.
SX_TMPN4 (number of male partners) >= 1, then SXMLONN4 (male only partners) = 1; else
Calculation_SXMLONN4 SXMLONN4 = 0.

So, the total number of people you had vaginal or anal sex with during the past 12 months
was [INSERT SX_TOTN4]?

ST.9.0.
SXTOVRN4

0
No
1
Yes
Don't know
8
7
Refused to answer
If SX_TOTN4 = 1, then display the text as follows: "So, you only had vaginal or anal sex with one
person during the past 12 months?
If ST.9.0. = 0 (no) or 8 (don't know), then read “Let me go back and reread the questions.” Return to
Skip2_SX_TFPN4.
Skip1_21_SXTOVRN4 If ST.9.0. = 7 (refused to answer), → S.0.a..
Skip2_N21_SXTOVRN4

No vaginal or anal sex partners: If ST.2.0., ST.3.0., and ST.4.0. are all some combination of 0, 7 (refused
to answer), or 8 (don't know), then → S.0.a.. Else, → Skip1_21_SX_NM1N4_21.

ST.5.0. – ST.9.0.

Page |61

Topic: Names of partners (SN)
SN.1.0.

Response:

Skip1_21_SX_NM1N4_21 If ST.5.0. = 1, → Intro1_21_SX_NM1N4_21. If ST.5.0. = 2-5, → Intro2_21_SXNM1N4_21.
Text2
If ST.5.0.> 5, skip to Intro3_21_SX_NM1N4_21.
Intro1_21_SX_NM1N4_21 "The next questions are about the person you had sex with during the past 12 months. I'll need a way
Text2
to refer to this person. You may refer to them in any way you want—initials, nickname, or where you
met. However, please don't provide a last name or any other identifying information."
Skip2_5_SX_NM1N4_21 → SN.1.0..
Text2
Intro2_21_SX_NM1N4_21 “The next questions are about the [ST.5.0.: if 2, 3, 4, or 5] people you had sex with during the past 12
Text2
months. Please answer to the best of your knowledge, but it’s okay to tell me you don’t know. I’ll
need a way to refer to each person. You may refer to them in any way you want—initials, nickname,
or where you met. However, please don’t provide a last name or any other identifying information.”
Skip3_5_SX_NM1N4_21
Text2
→ SN.1.0..
Intro3_21_SX_NM1N4_21
Text2
“The next questions are about the 5 people you recently had sex with during the past 12 months.
Please answer to the best of your knowledge, but it’s okay to tell me you don’t know. I’ll need a way
to refer to each person. You may refer to them in any way you want—initials, nickname, or where you
met. However, please don’t provide a last name or any other identifying information.”
Skip4_5_SX_NM1N4_21 → SN.1.0..
SX_NM1N4_21 What should we call the last person you had sex with during the past 12 months?

77
Refused to answer
(Range: Character limit = 50)
If SX_TOTN4 is 1, then display the text as follows: What should we call the person you had sex with
during the past 12 months?
If SN.1.0. is 7 (refused to answer), then read the message, Interviewer: remind the respondent that
they can provide initials, nicknames, or another name to identify the partner. Allow program to move
forward.
Skip5_21_SX_NM1N4_21 If ST.5.0. = 1 and SN.1.0. is 7 (refused to answer), → S.0.a.. If ST.5.0. is > 1, → SN.1.1..
If ST.5.0. is 1, → Intro_N21_SXPGN1N4.
SN.1.1.

Response:
SX_NM2N4_21 What should we call the 2nd person you had sex with during the past 12 months?

77
Refused to answer
(Range: Character limit = 50)
If SN.1.1. is 7 (refused to answer), read, Interviewer: remind the respondent that they can provide
initials, nicknames, or another name to identify the partner. Allow program to move forward.
If SN.1.0. and SN.1.1. are identical, then read, “You gave me the same name for another partner. Can
you please give me another name?” The program should return to SN.1.1..
Skip_21_SX_NM2N4_21 If ST.5.0. = 2 and SN.1.0. and SN.1.1. are 7 (refused to answer), → S.0.a..
If ST.5.0. >2, → SN.1.2..Else, → Skip1_21_SXPGN1N4.

SN.1.0. – SN.1.1.

Page |62
SN.1.2.

Response:
SX_NM3N4_21 What should we call the 3rd person you had sex with during the past 12 months?

77
Refused to answer
(Range: Character limit = 50)
If SN.1.2. is 7 (refused to answer), read, Interviewer: remind the respondent that they can provide
initials, nicknames, or another name to identify the partner. Allow program to move forward.
If either SN.1.0., SN.1.1., or SN.1.2. are identical, then read, “You gave me the same name for another
partner. Can you please give me another name?” The program should return to SN.1.2..
Skip_SX_NM3N4_21 If ST.5.0. = 3 and SN.1.0., SN.1.1. and SN.1.2. are 7 (refused to answer), → S.0.a..
If ST.5.0. > 3, → SN.1.3.. Else → Skip1_21_SXPGN1N4.
SN.1.3.

Response:
SX_NM4N4_21 What should we call the 4th person you had sex with during the past 12 months?

77
Refused to answer
(Range: Character limit = 50)
If SN.1.3. is 7 (refused to answer), read, Interviewer: remind the respondent that they can provide
initials, nicknames, or another name to identify the partner. Allow program to move forward.
If either SN.1.0., SN.1.1., SN.1.2., or SN.1.3. are identical, then read, “You gave me the same name for
another partner. Can you please give me another name?” The program should return to SN.1.3..
Skip_SX_NM4N4_21 If ST.5.0. = 4 and SN.1.0., SN.1.1., SN.1.2. and SN.1.3. are 7 (refused to answer), → S.0.a..
If ST.5.0. > 4, → SN.1.4.. Else, → Skip1_21_SXPGN1N4.
SN.1.4.

Response:
SX_NM5N4_21 What should we call the 5th person you had sex with in the past 12 months?

77
Refused to answer
(Range: Character limit = 50)
If SN.1.4. is 7 (refused to answer), read, Interviewer: remind the respondent that they can provide
initials, nicknames, or another name to identify the partner. Allow program to move forward.
If either SN.1.0., SN.1.1., SN.1.2., SN.1.3. or SN.1.4. are identical, then read, “You gave me the same
name for another partner. Can you please give me another name?” The program should return to
SN.1.4..
Skip_SX_NM5N4_21 If ST.5.0. = 5 and SN.1.0., SN.1.1., SN.1.2., SN.1.3., SN.1.4. are all 7 (refused to answer), → S.0.a..
If ST.5.0.> 5 and SN.1.0., SN.1.1., SN.1.2., SN.1.3., and SN.1.4. are all 7 (refused to answer), then →
Skip_21_SXAGC1N4. Else, → Skip1_21_SXPGN1N4.

SN.1.2. – SN.1.4.

Page |63

Topic: Partner demographics #1 (SP)
Response:

SP.1.0.

Skip 1_21_SXPGN1N4If SN.1.0. = 7 (refused to answer), → Skip_21_PREP1N4_21. Else, → Intro_N21_SXPGN1N4

(partner sex - partner 1).
Intro_N21_SXPGN1N4 "Now I'm going to ask you about [INSERT SN.1.0.]."
Skip 2_21_SXPGN1N4 Skip partner sex questions if the respondent had sex with only one sex

If ST.8.0. = 1, or ST.6.0. = 1 or ST.7.0. = 1, → SP.2.0.. Else, → SP.1.0..
SXPGN1N4 Is [INSERT SX_NM1N4_21] male or female?

1
2
8
7

Male
Female
Don't know
Refused to answer

If ST.1.0. = 2 (female) and SP.1.0. = female (2), read, “Only include people with whom you had vaginal
or anal sex. Remember, for these questions, vaginal sex means penis in the vagina and anal sex means
penis in the anus." Interviewer instructions: Return to previous question if necessary. Allow survey to
move forward.
Response:

SP.2.0.

SXPEN1N4 Is [INSERT SX_NM1N4_21] Hispanic, Latino/a, or of Spanish origin? If you’re not sure, give me your

best guess.
0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

SP.3.0.

SXPR1N4 Which of the following racial group or groups best describes [INSERT SX_NM1N4_21]? Select all that

apply. If you’re not sure, give me your best guess. [READ RESPONSES. SELECT ALL THAT APPLY.]
Response:

SP.3.0.
SXPR1N4A American Indian or Alaskan Native

0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

SP.3.0.
SXPR1N4B Asian

0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

SP.3.0.
SXPR1N4C Black or African American

0
1
8
7

No
Yes
Don't know
Refused to answer
SP.1.0. – SP.3.0.

Page |64
Response:

SP.3.0.
SXPR1N4D Native Hawaiian or Other Pacific Islander

0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

SP.3.0.
SXPR1N4E White

0
1
8
7

No
Yes
Don't know
Refused to answer

Topic: Vaginal sex #1 (SV)
Response:

SV.1.0.
Skip_21_SX_VS1N4 Male-male partners:

If ST.1.0. = 1 (male) and ST.7.0. = 1 or if ST.1.0. = 1 (male) and SP.1.0. = 1 (male), then → SL.1.0..
Female-female partners:
If ST.1.0. = 2 (female) and SP.1.0. = 2 (female), → Skip_21_PREP1N4_21.
Else, → SV.1.0..

SX_VS1N4 During the past 12 months, did you have vaginal sex with [INSERT SX_NM1N4_21]?

No
0
1
Yes
8
Don't know
7
Refused to answer
Skip2_21_SX_VS1N4 If SV.1.0. = 0 (no), 7 (refused), or 8 (don't know), → SL.1.0..
Else if SV.1.0. = 1 (yes), → Intro_21_SXVC1BN4_21.
SV.1.1.

Response:

Intro_21_SXVC1BN4_21 “The next question is about condom use. Please include when a condom was used the entire time, not
Text2
only part of the time during sex.”
SXVC1BN4_21 During the past 12 months when you had vaginal sex, how often did you or [INSERT SX_NM1N4_21]
use a condom? [READ RESPONSES. SELECT ONLY ONE.]
1
Never - not even once
2
Sometimes
3
Absolutely every time
8
Don't know
7
Refused to answer

SP.3.0. – SV.1.1.

Page |65

Topic: Anal sex #1 (SL)
Response:

SL.1.0.

SXANL1N4 During the past 12 months, did you have anal sex with [INSERT SX_NM1N4_21]?

0
No
1
Yes
8
Don't know
7
Refused to answer
No anal sex partners reported among male respondents who previously said they had only male
partners: If ST.1.0. = 1 (male) and if SP.1.0. = 1 (male) or ST.7.0. =1 and SL.1.0. = 0 (no), then read
“Earlier you told me that you had anal sex with [INSERT SN.1.0.]. Is this correct?” Interviewer
instructions: Return to previous questions to correct error. Allow program to move forward.
No vaginal or anal sex reported among males with female partners: If ST.1.0. = 1 (male) and SP.1.0. = 2
(female) or ST.6.0. = 1 and SV.1.0. = 0 (no) and SL.1.0. = 0 (no), then read “Earlier you told me that you
had vaginal or anal sex with [INSERT SN.1.0.]. Is this correct?” Interviewer instructions: Return to
previous questions to correct error. Allow program to move forward.
No vaginal or anal sex reported among females with male partners: If ST.1.0. = 2 (female) and SP.1.0. =
1 (male) or ST.7.0. =1 and SV.1.0. = 0 (no) and SL.1.0. = 0 (no), then read “Earlier you told me that you
had vaginal or anal sex with [INSERT SN.1.0.]. Is this correct?” Interviewer instructions: Return to
previous questions to correct error. Allow program to move forward.
Skip_21_SXANL1N4 If SL.1.0. = 1 (yes), → Intro_21_SXAC1BN4_21.
If SL.1.0. = 0 (no), 7 (refused) or 8 (don’t know), → SS.1.0..
Response:

SL.1.1.

Intro_21_SXAC1BN4_21 "The next question is about condom use. Please include when a condom was used the entire time, not
Text2
only part of the time."
SXAC1BN4_21 During the past 12 months when you had anal sex, how often did you or [INSERT SX_NM1N4_21]
use a condom? [READ RESPONSES. SELECT ONLY ONE.]
1
Never - not even once
2
Sometimes
3
Absolutely every time
8
Don't know
7
Refused to answer
Skip_21_SXAC1BN4_21 For all responses, → SS.1.0..

Topic: Vaginal or anal sex #1 (SG)
SG.1.0.

Response:
SX_TG1N4 During the past 12 months, did you have vaginal or anal sex with [INSERT SX_NM1N4_21]?

0
No
1
Yes
8
Don't know
7
Refused to answer
If SG.1.0. is 0 (no), then read, "Earlier you told me that you had vaginal or anal sex with [Insert
SN.1.0.]. Is this correct?" Interviewer instructions: return to previous questions to correct error. Allow
program to move forward.
Skip_21_SX_TG1N4 If SG.1.0. = 1 (yes), → Intro_21_TGC1BN4_21.
If SG.1.0. = 0 (no), 7 (refused) or 8 (don’t know), → SS.1.0..

SL.1.0. – SG.1.0.

Page |66
Response:

SG.1.1.

Intro_21_TGC1BN4_21 "The next question is about condom use. Please include times when a condom was used the entire
Text2
time, not only part of the time during sex.”
TGC1BN4_21 During the past 12 months when you had vaginal or anal sex, how often did you or [INSERT
SX_NM1N4_21] use a condom? [READ RESPONSES. SELECT ONLY ONE.]
1
Never - not even once
2
Sometimes
3
Absolutely every time
8
Don't know
7
Refused to answer

Topic: Status #1 (SS)
Response:

SS.1.0.
STPRT1N4 Do you know [INSERT SX_NM1N4_21]’s HIV status?

No
0
1
Yes
8
Don't know
7
Refused to answer
Skip_21_STPRT1N4 If SS.1.0. = 1 (yes), → SS.1.1.. Else, if ST.5.0. = 1 and SS.1.0. = 0 (no), 7 (refused) or 8 (don’t know), →
S.0.a.. Else, if ST.5.0. >1 and SS.1.0. = 0 (no), 7 (refused) or 8 (don’t know), → Skip1_21_SXPGN2N4.
Response:

SS.1.1.

PRTST1N4 During the past 12 months, what was [INSERT SX_NM1N4_21]’s HIV status the first time that you

had sex? [DON’T READ RESPONSES. SELECT ONLY ONE.]
1
HIV Positive
2
HIV Negative
8
Don't Know
7
Refused to answer
Skip_21_PRTST1N4 If SS.1.1. = 2 (HIV Negative), → Intro_PREP1N4_21. Else, if ST.5.0. = 1 and SS.1.1. = 1 (HIV Posi^ve), 7
(refused) or 8 (don’t know) , → S.0.a.. If ST.5.0. >1 and SS.1.1. = 1 (HIV posi^ve), 7 (refused) or 8
(don’t know), → Skip1_21_SXPGN2N4.

Topic: Pre-exposure prophylaxis #1 (SR)
SR.1.0.

Response:

Text2 Intro_PREP1N4_21 "Sometimes people who are HIV negative take antiretroviral medicine to prevent them from getting
HIV. This is called PrEP."
PREP1N4_21 Was [INSERT SX_NM1N4_21] taking PrEP when you last had sex? If you aren’t sure, that’s okay.
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_21_PREP1N4_21 If ST.5.0. = 1, → S.0.a.. If ST.5.0. >=2, → Skip1_21_SXPGN2N4.

SG.1.1. – SR.1.0.

Page |67

Topic: Partner demographics #2 (SP)
Response:

SP.1.0.
Text2Skip1_21_SXPGN2N4 If SN.1.1. = 7 (Refused to answer), → Skip2_21_PREP2N4_21.
Else, → Intro_N21_SXPGN2N4 (partner sex -partner 2). “Now
Intro_N21_SXPGN2N4 I’m going to ask you about [INSERT SN.1.1.].”
Text2
Skip2_21_SXPGN2N4 Skip partner sex questions if the respondent had sex with only one sex:
If ST.8.0. = 1 or ST.6.0. = 1 or ST.7.0. = 1, then → SP.2.0.. Else, → SP.1.0..
SXPGN2N4 Is [INSERT SX_NM2N4_21] male or female?

1
2
8
7

Male
Female
Don't know
Refused to answer

If SEX_25 = 2 (female) and SP.1.0. = female (2), read, “Only include people with whom you had vaginal
or anal sex. Remember, for these questions, vaginal sex means penis in the vagina and anal sex means
penis in the anus”. Interviewer instructions: Return to previous question if necessary. Allow survey to
move forward.
Response:

SP.2.0.

SXPEN2N4 Is [INSERT SX_NM2N4_21] Hispanic, Latino/a, or of Spanish origin? If you’re not sure, give me your

best guess.
0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

SP.3.0.

SXPR2N4 Which of the following racial group or groups best describes [INSERT SX_NM2N4_21]? Select all that

apply. If you're not sure, give me your best guess. [READ RESPONSES. SELECT ALL THAT APPLY.]
Response:

SP.3.0.
SXPR2N4A American Indian or Alaskan Native

0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

SP.3.0.
SXPR2N4B Asian

0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

SP.3.0.
SXPR2N4C Black or African American

0
1
8
7

No
Yes
Don't know
Refused to answer
SP.1.0. – SP.3.0.

Page |68
Response:

SP.3.0.
SXPR2N4D Native Hawaiian or Other Pacific Islander

0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

SP.3.0.
SXPR2N4E White

0
1
8
7

No
Yes
Don't know
Refused to answer

Topic: Vaginal sex #2 (SV)
Response:

SV.1.0.
Skip_21_SX_VS2N4 Male-male partners:

If ST.1.0. = 1 (male) and ST.7.0. = 1 or if ST.1.0. = 1 (male) and SP.1.0. = 1 (male), then → SL.1.0..
Female-female partners:
If ST.1.0. = 2 (female) and SP.1.0. = 2 (female), → Skip2_21_PREP2N4_21. Else → SV.1.0..

SX_VS2N4 During the past 12 months, did you have vaginal sex with [INSERT SX_NM2N4_21]?

0
No
1
Yes
8
Don't know
7
Refused to answer
Skip2_21_SX_VS2N4 If SV.1.0. = 0 (no), 7 (refused), or 8 (don't know), → SL.1.0.. Else, → SV.1.1..
Response:

SV.1.1.

SXVC2BN4_21 During the past 12 months when you had vaginal sex, how often did you or [INSERT SX_NM2N4_21]

use a condom? [READ RESPONSES. SELECT ONLY ONE.]
1
Never - not even once
2
Sometimes
3
Absolutely every time
8
Don't know
7
Refused to answer

SP.3.0. – SV.1.1.

Page |69

Topic: Anal sex #2 (SL)
Response:

SL.1.0.

SXANL2N4 During the past 12 months, did you have anal sex with [INSERT SX_NM2N4_21]?

0
No
1
Yes
8
Don't know
7
Refused to answer
No anal sex partners reported among male respondents who previously said they had only male
partners: If ST.1.0. = 1 (male) and if SP.1.0. = 1 or ST.7.0. = 1 and SL.1.0. =0 (no), then read “Earlier you
told me that you had anal sex with [INSERT SN.1.1.]. Is this correct?” Interviewer instructions: Return
to previous questions to correct error. Allow program to move forward.
No vaginal or anal sex reported among males with female partners: If ST.1.0. = 1 (male) and SP.1.0. =
2 (female) or ST.6.0. = 1 and SV.1.0. = 0 (no) and SL.1.0. = 0 (no), then read “Earlier you told me that
you had vaginal or anal sex with [INSERT SN.1.1.]. Is this correct?” Interviewer instructions: Return to
previous questions to correct error. Allow program to move forward.
No vaginal or anal sex reported among females with male partners: If ST.1.0. = 2 (female) and SP.1.0.
= 1 (male) or ST.7.0. =1 and SV.1.0. = 0 (no) and SL.1.0. = 0 (no), then read “Earlier you told me that
you had vaginal or anal sex with [INSERT SN.1.1.]. Is this correct?” Interviewer instructions: Return to
previous questions to correct error. Allow program to move forward.
Skip_21_SXANL2N4 If SL.1.0. = 1 (yes), → SL.1.1.. If SL.1.0. = 0 (no), 7 (refused) or 8 (don’t know), → SS.1.0..
Response:

SL.1.1.

SXAC2BN4_21 During the past 12 months when you had anal sex, how often did you or [INSERT SX_NM2N4_21]

use a condom? [READ RESPONSES. SELECT ONLY ONE.]
1
Never - not even once
2
Sometimes
3
Absolutely every time
8
Don't know
7
Refused to answer
Skip_21_SXAC2BN4_21 For all responses, → SS.1.0..

Topic: Vaginal or anal sex #2 (SG)
SG.1.0.

Response:
SX_TG2N4 During the past 12 months, did you have vaginal or anal sex with [INSERT SX_NM2N4_21]?

0
No
1
Yes
8
Don't know
7
Refused to answer
If SG.1.0. is 0 (no), then read, "Earlier you told me that you had vaginal or anal sex with [Insert
SN.1.1.]. Is this correct?" Interviewer instructions: return to previous questions to correct error. Allow
program to move forward.
Skip_21_SX_TG2N4 If SG.1.0. = 1 (yes), → SG.1.1.. If SG.1.0. = 0 (no), 7 (refused), or 8 (don’t know), → SS.1.0..

SL.1.0. – SG.1.0.

Page |70
Response:

SG.1.1.

TGC2BN4_21 During the past 12 months when you had vaginal or anal sex, how often did you or [INSERT

SX_NM2N4_21] use a condom? [READ RESPONSES. SELECT ONLY ONE.]
1
Never - not even once
2
Sometimes
3
Absolutely every time
8
Don't know
7
Refused to answer

Topic: Status #2 (SS)
Response:

SS.1.0.
STPRT2N4 Do you know [INSERT SX_NM2N4_21]’s HIV status?

No
0
1
Yes
8
Don't know
7
Refused to answer
Skip_21_STPRT2N4 If SS.1.0. = 1 (yes), → SS.1.1.. Else, if ST.5.0. = 2 and SS.1.0. = 0 (no), 7 (refused) or 8 (don’t know), →
S.0.a.. Else, if ST.5.0. > 2 and SS.1.0. = 0 (no), 7 (refused) or 8 (don’t know), → Skip1_21_SXPGN3N4.
Response:

SS.1.1.

PRTST2N4 During the past 12 months, what was [INSERT SX_NM2N4_21]’s HIV status the first time that you

had sex? [DON’T READ RESPONSES. SELECT ONLY ONE.]
1
HIV Positive
2
HIV Negative
8
Don't Know
7
Refused to answer
Skip_21_PRTST2N4 If SS.1.1. = 2 (HIV Negative), → Skip1_21_PREP2N4_21. Else, if ST.5.0. = 2 and SS.1.1. = 1 (HIV
posi^ve), 7 (refused) or 8 (don’t know), → S.0.a.. If ST.5.0. >2 and SS.1.1. = 1 (HIV posi^ve), 7 (refused)
or 8 (don’t know), → Skip1_21_SXPGN3N4.

Topic: Pre-exposure prophylaxis #2 (SR)
SR.1.0.

Response:

Skip1_21_PREP2N4_21 If SS.1.1. = 2 (HIV negative), → SR.1.0.. If SS.1.1. = 1 (HIV Posi^ve), 7 (refused) or 8 (don't know), →
Text2
Intro_PREP2N4_21.
Intro_PREP2N4_21
Text2
"Sometimes people who are HIV negative take antiretroviral medicine to prevent them from getting
HIV. This is called PrEP."
PREP2N4_21 Was [INSERT SX_NM2N4_21] taking PrEP when you last had sex? If you aren’t sure, that’s okay.
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip2_21_PREP2N4_21 If ST.5.0. = 2, → S.0.a.. If ST.5.0. >2, → Skip1_21_SXPGN3N4.

SG.1.1. – SR.1.0.

Page |71

Topic: Partner demographics #3 (SP)
SP.1.0.

Response:

Text2Skip1_21_SXPGN3N4 If SN.1.2. = 7 (refused to answer), → Skip2_21_PREP3N4_21. Else, → Intro_N21_SXPGN3N4 (partner
sex -partner 3).
Intro_N21_SXPGN3N4 “Now I’m going to ask you about [INSERT SN.1.2.].”
Text2
Skip2_21_SXPGN3N4 Skip partner sex questions if the respondent had sex with only one sex:
If ST.8.0. = 1, or ST.6.0. = 1 or ST.7.0. = 1, then → SP.2.0.. Else, → SP.1.0..
SXPGN3N4 Is [INSERT SX_NM3N4_21] male or female?

1
2
8
7

Male
Female
Don't know
Refused to answer

If SEX_25 = 2 (female) and SP.1.0. = female (2), read, “Only include people with whom you had vaginal
or anal sex. Remember, for these questions, vaginal sex means penis in the vagina and anal sex means
penis in the anus”. Interviewer instructions: Return to previous question if necessary. Allow survey to
move forward.
Response:

SP.2.0.

SXPEN3N4 Is [INSERT SX_NM3N4_21] Hispanic, Latino/a, or of Spanish origin? If you’re not sure, give me your

best guess.
0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

SP.3.0.

SXPR3N4 Which of the following racial group or groups best describes [INSERT SX_NM3N4_21]? Select all that

apply. If you're not sure, give me your best guess. [READ RESPONSES. SELECT ALL THAT APPLY.]
Response:

SP.3.0.
SXPR3N4A American Indian or Alaskan Native

0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

SP.3.0.
SXPR3N4B Asian

0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

SP.3.0.
SXPR3N4C Black or African American

0
1
8
7

No
Yes
Don't know
Refused to answer
SP.1.0. – SP.3.0.

Page |72
Response:

SP.3.0.
SXPR3N4D Native Hawaiian or Other Pacific Islander

0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

SP.3.0.
SXPR3N4E White

0
1
8
7

No
Yes
Don't know
Refused to answer

Topic: Vaginal sex #3 (SV)
Response:

SV.1.0.
Skip_21_SX_VS3N4 Male-male partners:

If ST.1.0. = 1 (male) and ST.7.0. = 1 or if ST.1.0. = 1 (male) and SP.1.0. = 1 (male), then → SL.1.0..
Female-female partners:
If ST.1.0. = 2 (female) and SP.1.0. = 2 (female), → Skip2_21_PREP3N4_21.
Else→ SV.1.0..

SX_VS3N4 During the past 12 months, did you have vaginal sex with [INSERT SX_NM3N4_21]?

No
0
1
Yes
8
Don't know
7
Refused to answer
Skip2_21_SX_VS3N4 If SV.1.0. = 0 (no), 7 (refused), or 8 (don't know), → SL.1.0..
Else if SV.1.0.= 1 (yes), → SV.1.1..
Response:

SV.1.1.

SXVC3BN4_21 During the past 12 months when you had vaginal sex, how often did you or [INSERT SX_NM3N4_21]

use a condom? [READ RESPONSES. SELECT ONLY ONE.]
1
Never - not even once
2
Sometimes
3
Absolutely every time
8
Don't know
7
Refused to answer

SP.3.0. – SV.1.1.

Page |73

Topic: Anal sex #3 (SL)
SL.1.0.

Response:
SXANL3N4 During the past 12 months, did you have anal sex with [INSERT SX_NM3N4_21]?

0
No
1
Yes
8
Don't know
7
Refused to answer
No anal sex partners reported among male respondents who previously said they had only male
partners: If ST.1.0. = 1 (male) and if SP.1.0. = 1 (male) or ST.7.0. =1 (yes) and SL.1.0. = 0 (no), then read
“Earlier you told me that you had anal sex with [INSERT SN.1.2.]. Is this correct?” Interviewer
instructions: Return to previous questions to correct error. Allow program to move forward.
No vaginal or anal sex reported among males with female partners: If ST.1.0. = 1 (male) and SP.1.0. = 2
(female) or ST.6.0. = 1 and SV.1.0. = 0 (no) and SL.1.0. = 0 (no), then read “Earlier you told me that
you had vaginal or anal sex with [INSERT SN.1.2.]. Is this correct?” Interviewer instructions: Return to
previous questions to correct error. Allow program to move forward.
No vaginal or anal sex reported among females with male partners: If ST.1.0. = 2 (female) and SP.1.0.
= 1 (male) or ST.7.0. =1 and SV.1.0. = 0 (no) and SL.1.0. = 0 (no), then read “Earlier you told me that
you had vaginal or anal sex with [INSERT SN.1.2.]. Is this correct?” Interviewer instructions: Return to
previous questions to correct error. Allow program to move forward.
Skip_21_SXANL3N4 If SL.1.0. = 1 (yes), → SL.1.1.. If SL.1.0. = 0 (no), 7 (refused) or 8 (don’t know), → SS.1.0..
Response:

SL.1.1.

SXAC3BN4_21 During the past 12 months when you had anal sex, how often did you or [INSERT SX_NM3N4_21]

use a condom? [READ RESPONSES. SELECT ONLY ONE.]
1
Never - not even once
2
Sometimes
3
Absolutely every time
8
Don't know
7
Refused to answer
Skip_21_SXAC3BN4_21 For all responses, → SS.1.0..

Topic: Vaginal or anal sex #3 (SG)
SG.1.0.

Response:
SX_TG3N4 During the past 12 months, did you have vaginal or anal sex with [INSERT SX_NM3N4_21]?

0
No
1
Yes
8
Don't know
7
Refused to answer
If SG.1.0. is 0 (no), then read, "Earlier you told me that you had vaginal or anal sex with [Insert
SN.1.2.]. Is this correct?" Interviewer instructions: return to previous questions to correct error. Allow
program to move forward.
Skip_21_SX_TG3N4 If SG.1.0. = 1 (yes), → SG.1.1.. If SG.1.0. = 0 (no), 7 (refused) or 8 (don’t know), → SS.1.0..

SL.1.0. – SG.1.0.

Page |74
Response:

SG.1.1.

TGC3BN4_21 During the past 12 months when you had vaginal or anal sex, how often did you or [INSERT

SX_NM3N4_21] use a condom? [READ RESPONSES. SELECT ONLY ONE.]
Never - not even once
1
2
Sometimes
3
Absolutely every time
8
Don't know
7
Refused to answer

Topic: Status #3 (SS)
Response:

SS.1.0.
STPRT3N4 Do you know [INSERT SX_NM3N4_21]’s HIV status?

No
0
1
Yes
8
Don't know
7
Refused to answer
Skip_21_STPRT3N4 If SS.1.0. = 1 (yes), → SS.1.1.. Else, if ST.5.0. = 3 and SS.1.0. = 0 (no), 7 (refused) or 8 (don’t know), →
S.0.a.. Else, if ST.5.0. >3 and SS.1.0. = 0 (no), 7 (refused) or 8 (don’t know), → Skip1_21_SXPGN4N4.
Response:

SS.1.1.

PRTST3N4 During the past 12 months, what was [INSERT SX_NM3N4_21]’s HIV status the first time that you

had sex? [DON’T READ RESPONSES. SELECT ONLY ONE.]
1
HIV Positive
2
HIV Negative
8
Don't Know
7
Refused to answer
Skip_21_PRTST3N4 If SS.1.1. = 2 (HIV Negative), → Skip1_21_PREP3N4_21. Else, if ST.5.0. = 3 and SS.1.1.=1 (HIV Posi^ve),
7 (refused) or 8 (don’t know), → S.0.a.. If ST.5.0. >3 and SS.1.1.=1 (HIV Posi^ve), 7 (refused) or 8
(don’t know), → Skip1_21_SXPGN4N4.

Topic: Pre-exposure prophylaxis #3 (SR)
SR.1.0.

Response:

Skip1_21_PREP3N4_21 If SS.1.1. = 2 (HIV negative) or SS.1.1. = 2 (HIV negative), → SR.1.0.. Else, → Intro_PREP3N4_21.
Text2
Text2 Intro_PREP3N4_21 "Sometimes people who are HIV negative take antiretroviral medicine to prevent them from getting
HIV. This is called PrEP."
PREP3N4_21 Was [INSERT SX_NM3N4_21] taking PrEP when you last had sex? If you aren’t sure, that’s okay.
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip2_21_PREP3N4_21 If ST.5.0. = 3, → S.0.a.. If ST.5.0. >3, → Skip1_21_SXPGN4N4.

SG.1.1. – SR.1.0.

Page |75

Topic: Partner demographics #4 (SP)
SP.1.0.

Response:

Text2Skip1_21_SXPGN4N4 If SN.1.3. = 7 (refused to answer), → Skip2_21_PREP4N4_21.
Else, → Intro_N21_SXPGN4N4 (partner sex - partner 4).
Intro_N21_SXPGN4N4 “Now I’m going to ask you about [INSERT SN.1.3.].”
Text2
Skip2_21_SXPGN4N4 Skip partner sex questions if the respondent had sex with only one sex:
If ST.8.0. = 1, or ST.6.0.= 1 or ST.7.0. = 1, then → SP.2.0. Else, →SP.1.0.
SXPGN4N4 Is [INSERT SX_NM4N4_21] male or female?

1
2
8
7

Male
Female
Don't know
Refused to answer

If SEX_25 = 2 (female) and SP.1.0. = 2 (female), read, “Only include people with whom you had vaginal
or anal sex. Remember, for these questions, vaginal sex means penis in the vagina and anal sex means
penis in the anus”. Interviewer instructions: Return to previous question if necessary. Allow survey to
move forward.
Response:

SP.2.0.

SXPEN4N4 Is [INSERT SX_NM4N4_21] Hispanic, Latino/a, or of Spanish origin? If you’re not sure, give me your

best guess.
0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

SP.3.0.

SXPR4N4 Which of the following racial group or groups best describes [INSERT SX_NM4N4_21]? Select all that

apply. If you're not sure, give me your best guess. [READ RESPONSES. SELECT ALL THAT APPLY.]
Response:

SP.3.0.
SXPR4N4A American Indian or Alaskan Native

0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

SP.3.0.
SXPR4N4B Asian

0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

SP.3.0.
SXPR4N4C Black or African American

0
1
8
7

No
Yes
Don't know
Refused to answer
SP.1.0. – SP.3.0.

Page |76
Response:

SP.3.0.
SXPR4N4D Native Hawaiian or Other Pacific Islander

0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

SP.3.0.
SXPR4N4E White

0
1
8
7

No
Yes
Don't know
Refused to answer

Topic: Vaginal sex #4 (SV)
Response:

SV.1.0.
Skip_21_SX_VS4N4 Male-male partners:

If ST.1.0. = 1 (male) and ST.7.0. = 1 or if ST.1.0. = 1 (male) and SP.1.0. = 1 (male), then → SL.1.0..
Female-female partners:
If ST.1.0. = 2 (female) and SP.1.0. = 2 (female), → Skip2_21_PREP4N4_21. Else → SV.1.0..

SX_VS4N4 During the past 12 months, did you have vaginal sex with [INSERT SX_NM4N4_21]?

0
No
1
Yes
8
Don't know
7
Refused to answer
Skip2_21_SX_VS4N4 If SV.1.0. = 0 (no), 7 (refused), or 8 (don't know), → SL.1.0.. Else if SV.1.0.= 1 (yes), → SV.1.1..
Response:

SV.1.1.

SXVC4BN4_21 During the past 12 months when you had vaginal sex, how often did you or [INSERT SX_NM4N4_21]

use a condom? [READ RESPONSES. SELECT ONLY ONE.]
1
Never - not even once
2
Sometimes
3
Absolutely every time
8
Don't know
7
Refused to answer

SP.3.0. – SV.1.1.

Page |77

Topic: Anal sex #4 (SL)
SL.1.0.

Response:
SXANL4N4 During the past 12 months, did you have anal sex with [INSERT SX_NM4N4_21]?

0
No
1
Yes
8
Don't know
7
Refused to answer
No anal sex partners reported among male respondents who previously said they had only male
partners: If ST.1.0. = 1 (male) and if SP.1.0. = 1 or ST.7.0. =1 and SL.1.0. is 0 (no), then read “Earlier you
told me that you had anal sex with [INSERT SN.1.3.]. Is this correct?” Interviewer instructions: Return
to previous questions to correct error. Allow program to move forward.
No vaginal or anal sex reported among males with female partners: If ST.1.0. = 1 (male) and SP.1.0. = 2
(female) or ST.6.0. = 1 and SV.1.0. = 0 (no) and SL.1.0. = 0 (no), then read “Earlier you told me that you
had vaginal or anal sex with [INSERT SN.1.3.]. Is this correct?” Interviewer instructions: Return to
previous questions to correct error. Allow program to move forward.
No vaginal or anal sex reported among females with male partners: If ST.1.0. = 2 (female) and SP.1.0. =
1 (male) or ST.7.0. =1 and SV.1.0. = 0 (no) and SL.1.0. = 0 (no), then read “Earlier you told me that you
had vaginal or anal sex with [INSERT SN.1.3.]. Is this correct?” Interviewer instructions: Return to
previous questions to correct error. Allow program to move forward.
Skip_21_SXANL4N4 If SL.1.0. = 1 (yes), → SL.1.1.. If SL.1.0. = 0 (no), 7 (refused) or 8 (don’t know), → SS.1.0..
Response:

SL.1.1.

SXAC4BN4_21 During the past 12 months when you had anal sex, how often did you or [INSERT SX_NM4N4_21]

use a condom? [READ RESPONSES. SELECT ONLY ONE.]
1
Never - not even once
2
Sometimes
3
Absolutely every time
8
Don't know
7
Refused to answer
Skip_21_SXAC4BN4_21 For all responses, → SS.1.0..

Topic: Vaginal or anal sex #4 (SG)
SG.1.0.

Response:
SX_TG4N4 During the past 12 months, did you have vaginal or anal sex with [INSERT SX_NM4N4_21]?

0
No
1
Yes
8
Don't know
7
Refused to answer
If SG.1.0. is 0 (no), then read, "Earlier you told me that you had vaginal or anal sex with [Insert
SN.1.3.]. Is this correct?" Interviewer instructions: return to previous questions to correct error. Allow
program to move forward.
Skip_21_SX_TG4N4 If SG.1.0. = 1 (yes), → SG.1.1.. If SG.1.0. = 0 (no), 7 (refused) or 8 (don’t know), → SS.1.0..

SL.1.0. – SG.1.0.

Page |78
Response:

SG.1.1.

TGC4BN4_21 During the past 12 months when you had vaginal or anal sex, how often did you or [INSERT

SX_NM4N4_21] use a condom? [READ RESPONSES. SELECT ONLY ONE.]
Never - not even once
1
2
Sometimes
3
Absolutely every time
8
Don't know
7
Refused to answer

Topic: Status #4 (SS)
Response:

SS.1.0.
STPRT4N4 Do you know [INSERT SX_NM4N4_21]’s HIV status?

No
0
1
Yes
8
Don't know
7
Refused to answer
Skip_21_STPRT4N4 If SS.1.0. = 1 (yes), → SS.1.1.. Else, if ST.5.0. = 4 and SS.1.0.= 0 (no), 7 (refused) or 8 (don’t know), →
S.0.a.. Else, if ST.5.0. > 4 and SS.1.0.= 0 (no), 7 (refused) or 8 (don’t know), → Skip1_21_SXPGN5N4.
Response:

SS.1.1.

PRTST4N4 During the past 12 months, what was [INSERT SX_NM4N4_21]’s HIV status the first time that you

had sex? [DON’T READ RESPONSES. SELECT ONLY ONE.]
1
HIV Positive
2
HIV Negative
8
Don't Know
7
Refused to answer
Skip_21_PRTST4N4 If SS.1.1. = 2 (HIV Negative), → Skip1_21_PREP4N4_21. Else, if ST.5.0. = 4 and SS.1.1.= 1 (HIV
posi^ve), 7 (refused) or 8 (don’t know), → S.0.a.. If ST.5.0. > 4 and SS.1.1.= 1 (HIV posi^ve), 7
(refused) or 8 (don’t know), → Skip1_21_SXPGN5N4.

Topic: Pre-exposure prophylaxis #4 (SR)
SR.1.0.

Response:

Skip1_21_PREP4N4_21 If SS.1.1. = 2 (HIV negative) or SS.1.1. = 2 (HIV negative), or SS.1.1. = 2 (HIV negative), → SR.1.0..
Text2
Else, → Intro_PREP4N4_21.
Intro_PREP4N4_21
Text2
"Sometimes people who are HIV negative take antiretroviral medicine to prevent them from getting
HIV. This is called PrEP."
PREP4N4_21 Was [INSERT SX_NM4N4_21] taking PrEP when you last had sex? If you aren’t sure, that’s okay.
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip2_21_PREP4N4_21 If ST.5.0. = 4, → S.0.a.. If ST.5.0. >4, → Skip1_21_SXPGN5N4.

SG.1.1. – SR.1.0.

Page |79

Topic: Partner demographics #5 (SP)
SP.1.0.

Response:

Text2Skip1_21_SXPGN5N4 If SN.1.4. = 7 (refused to answer), → Skip2_21_PREP5N4_21.
Else, → Intro_N21_SXPGN5N4 (partner sex - partner 5).
Intro_N21_SXPGN5N4 “Now I’m going to ask you about [INSERT SN.1.4.].”
Text2
Skip2_21_SXPGN5N4 Skip partner sex questions if the respondent had sex with only one sex:
If ST.8.0. = 1, or ST.6.0. = 1 or ST.7.0. = 1, then → SP.2.0..Else, → SP.1.0..
SXPGN5N4 Is [INSERT SX_NM5N4_21] male or female? [READ RESPONSES. SELECT ONLY ONE.]

1
2
8
7

Male
Female
Don't know
Refused to answer

If SEX_25= 2 (female) and SP.1.0. = 2 (female), read, “Only include people with whom you had vaginal
or anal sex. Remember, for these questions, vaginal sex means penis in the vagina and anal sex means
penis in the anus”. Interviewer instructions: Return to previous question if necessary. Allow survey to
move forward.
Response:

SP.2.0.

SXPEN5N4 Is [INSERT SX_NM5N4_21] Hispanic, Latino/a, or of Spanish origin? If you’re not sure, give me your

best guess.
0
No
1
Yes
8
Don't know
7
Refused to answer
Skip_SXPEN5N4 For all responses → SP.3.0..
Response:

SP.3.0.

SXPR5N4 Which of the following racial group or groups best describes [INSERT SX_NM5N4_21]? Select all that

apply. If you're not sure, give me your best guess. [READ RESPONSES. SELECT ALL THAT APPLY.]
Response:

SP.3.0.
SXPR5N4A American Indian or Alaskan Native

0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

SP.3.0.
SXPR5N4B Asian

0
1
8
7

No
Yes
Don't know
Refused to answer

SP.1.0. – SP.3.0.

Page |80
Response:

SP.3.0.
SXPR5N4C Black or African American

0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

SP.3.0.
SXPR5N4D Native Hawaiian or Other Pacific Islander

0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

SP.3.0.
SXPR5N4E White

0
1
8
7

No
Yes
Don't know
Refused to answer

Topic: Vaginal sex #5 (SV)
Response:

SV.1.0.
Skip_21_SX_VS5N4 Male-male partners:

If ST.1.0. = 1 (male) and ST.7.0. = 1 or if ST.1.0. = 1 (male) and SP.1.0. = 1 (male), then → SL.1.0..
Female-female partners:
If ST.1.0. = 2 (female) and SP.1.0. = 2 (female), → Skip2_21_PREP5N4_21. Else → SV.1.0..

SX_VS5N4 During the past 12 months, did you have vaginal sex with [INSERT SX_NM5N4_21]?

0
No
1
Yes
8
Don't know
7
Refused to answer
Skip2_21_SX_VS5N4 If SV.1.0. = 0 (no), 7 (refused), or 8 (don't know), → SL.1.0.. Else if SV.1.0.= 1 (yes), → SV.1.1..
Response:

SV.1.1.

SXVC5BN4_21 During the past 12 months when you had vaginal sex, how often did you or [INSERT SX_NM5N4_21]

use a condom? [READ RESPONSES. SELECT ONLY ONE.]
1
Never - not even once
2
Sometimes
3
Absolutely every time
8
Don't know
7
Refused to answer

SP.3.0. – SV.1.1.

Page |81

Topic: Anal sex #5 (SL)
SL.1.0.

Response:
SXANL5N4 During the past 12 months, did you have anal sex with [INSERT SX_NM5N4_21]?

0
No
1
Yes
8
Don't know
7
Refused to answer
No anal sex partners reported among male respondents who previously said they had only male
partners: If ST.1.0. = 1 (male) and if SP.1.0. = 1 (male) or ST.7.0. =1 and SL.1.0. = 0 (no), then read
“Earlier you told me that you had anal sex with [INSERT SN.1.4.]. Is this correct?” Interviewer
instructions: Return to previous questions to correct error. Allow program to move forward.
No vaginal or anal sex reported among males with female partners: If ST.1.0. = 1 (male) and SP.1.0. =
2 (female) or ST.6.0. = 1 and SV.1.0. = 0 (no) and SL.1.0. = 0 (no), then read “Earlier you told me that
you had vaginal or anal sex with [INSERT SN.1.4.]. Is this correct?” Interviewer instructions: Return to
previous questions to correct error. Allow program to move forward.
No vaginal or anal sex reported among females with male partners: If ST.1.0. = 2 (female) and SP.1.0.
= 1 (male) or ST.7.0. =1 and SV.1.0. = 0 (no) and SL.1.0. = 0 (no), then read “Earlier you told me that
you had vaginal or anal sex with [INSERT SN.1.4.]. Is this correct?” Interviewer instructions: Return to
previous questions to correct error. Allow program to move forward.
Skip_21_SXANL5N4 If SL.1.0. = 1 (yes), → SL.1.1.. If SL.1.0. = 0 (no), 7 (refused) or 8 (don’t know), → SS.1.0..
Response:

SL.1.1.

SXAC5BN4_21 During the past 12 months when you had anal sex, how often did you or [INSERT SX_NM5N4_21]

use a condom? [READ RESPONSES. SELECT ONLY ONE.]
1
Never - not even once
2
Sometimes
3
Absolutely every time
8
Don't know
7
Refused to answer
Skip_21_SXAC5BN4_21 For all responses, → SS.1.0..

Topic: Vaginal or anal sex #5 (SG)
SG.1.0.

Response:
SX_TG5N4 During the past 12 months, did you have vaginal or anal sex with [INSERT SX_NM5N4_21]?

0
No
1
Yes
8
Don't know
7
Refused to answer
If SG.1.0. is 0 (no), then read, "Earlier you told me that you had vaginal or anal sex with [Insert
SN.1.4.]. Is this correct?" Interviewer instructions: return to previous questions to correct error. Allow
program to move forward.
Skip_21_SX_TG5N4 If SG.1.0. = 1 (yes), → SG.1.1.. If SG.1.0. = 0 (no), 7 (refused) or 8 (don’t know), → SS.1.0..

SL.1.0. – SG.1.0.

Page |82
Response:

SG.1.1.

TGC5BN4_21 During the past 12 months when you had vaginal or anal sex, how often did you or [INSERT

SX_NM5N4_21] use a condom? [READ RESPONSES. SELECT ONLY ONE.]
1
Never - not even once
2
Sometimes
3
Absolutely every time
8
Don't know
7
Refused to answer

Topic: Status #5 (SS)
Response:

SS.1.0.
STPRT5N4 Do you know [INSERT SX_NM5N4_21]’s HIV status?

0
No
1
Yes
8
Don't know
7
Refused to answer
Skip_21_STPRT5N4 If SS.1.0. = 1 (yes), → SS.1.1.. Else, if ST.5.0. = 5 and SS.1.0. = 0 (no), 7 (refused) or 8 (don’t know), →
S.0.a.. Else, if ST.5.0. >5 and SS.1.0. = 0 (no), 7 (refused) or 8 (don’t know), → Skip_21_SXAGC1N4.
Response:

SS.1.1.

PRTST5N4 During the past 12 months, what was [INSERT SX_NM5N4_21]’s HIV status the first time that you

had sex? [DON’T READ RESPONSES. SELECT ONLY ONE.]
1
HIV Positive
2
HIV Negative
8
Don't Know
7
Refused to answer
Skip_21_PRTST5N4 If SS.1.1. = 2 (HIV Negative), → Skip1_21_PREP5N4_21. Else, if ST.5.0. = 5 and SS.1.1. = 1 (HIV
Posi^ve), 7 (refused) or 8 (don’t know), → S.0.a.. If ST.5.0. >5 and SS.1.1. = 1 (HIV Posi^ve), 7
(refused) or 8 (don’t know), → Skip_21_SXAGC1N4.

Topic: Pre-exposure prophylaxis #5 (SR)
SR.1.0.

Response:

Skip1_21_PREP5N4_21 If SS.1.1. = 2 (HIV negative) or SS.1.1. = 2 (HIV negative), or SS.1.1. = 2 (HIV negative), or SS.1.1. = 2
Text2
(HIV negative), → SR.1.0.. Else, → Intro_PREP5N4_21.
Intro_PREP5N4_21
Text2
"Sometimes people who are HIV negative take antiretroviral medicine to prevent them from getting
HIV. This is called PrEP."
PREP5N4_21 Was [INSERT SX_NM5N4_21] taking PrEP when you last had sex? If you aren’t sure, that’s okay.
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip2_21_PREP5N4_21 If ST.5.0. = 5, → S.0.a.. If ST.5.0. >5, → Skip_21_SXAGC1N4.

SG.1.1. – SR.1.0.

Page |83

Topic: Aggregate information (SA)
SA.1.0.

Response:

Text2 Skip_21_SXAGC1N4 If ST.5.0. = 6, → Intro_21_SXAGC1N4. If ST.5.0. > 6, → Intro_N21_SXAGC2N4.
Text2Intro_21_SXAGC1N4 “We just talked about the five people you recently had sex with. Now I’d like to ask you about the
other person you had sex with during the past 12 months.”
SXAGC1N4 During the past 12 months, was a condom always used when you had vaginal or anal sex with your
other partner?
0
No
1
Yes
8
Don't know
7
Refused to answer
Response:

SA.1.1.
SXAGP1N4 Was your other partner HIV positive?

0
No
1
Yes
8
Don't know
7
Refused to answer
Skip_21_SXAGP1N4_21 All responses → S.0.a..
SA.1.2.

Response:

Intro_N21_SXAGC2N4 “We just talked about the five people you most recently had sex with. Now I’d like to ask you about
Text2
the other people you had sex with during the past 12 months.”
SXAGC2N4 During the past 12 months, with how many of these [INSERT [SX_TOTN4] - 5] other partners was a
condom always used when you had vaginal or anal sex?
8888
Don't know
7777
Refused to answer
(Range: 0-2997)
If SA.1.2. is > [ST.5.0. - 5], then read the following: “The number of additional partners with whom you
used a condom cannot be greater than [insert value from (ST.5.0.) - 5]." Confirm Answer. Go back to
SA.1.2..
Skip_N21_SXAGC2N4 If SA.1.2. = [ST.5.0.-5], 7 (refused to answer) or 8 (don’t know), then → S.0.a.. Else, → SA.1.2a..

SA.1.2a.
Calculation_SXAGUPN4 Create a calculated variable to indicate the aggregate number of partners with whom the

respondent had sex without a condom. If SX_TOTN4 is > 5, then create SXAGUPN4 where
([SX_TOTN4 (total number of vaginal and anal sex partners)] - (minus) 5] - SXAGC2N4).
SA.1.3.

Response:
SXAGC3N4_21 So, you had sex without a condom with [INSERT SXAGUPN4] of these other partners?

0
No
1
Yes
8
Don't know
7
Refused to answer
If SA.1.3. is 0 (no), then read, “The number of partners with whom you had sex without a condom
does not add up.” Return to SA.1.2..
Skip_N21_SXAGC3N4_21 If SA.1.3. is 7777 (refused to answer) or 8888 (don’t know), → S.0.a..

SA.1.0. – SA.1.3.

Page |84
Response:

SA.1.4.

SXAGP2N4 How many of those [INSERT SXAGUPN4] other partners were HIV positive?

8888
Don't know
7777
Refused to answer
(Range: 0-2997)
SA.1.4. cannot be greater than SA.1.2a.. If SA.1.4. > SA.1.2a., then read, “The response is out of range”
and return to SA.1.4..
S.0.a.
Calculation_EN_SEXN5 EN_SEXN5 = Current time

SA.1.4. – S.0.a.

Page |85

Module: Violence (B)
Topic: Physical violence (BP)
Response:

BP.1.0.

Text2 Intro_21_IPVPH1N5 "Next, I’ll ask about experiences with romantic or sexual partners who may have physically hurt you.
This may include spouses, boyfriends, girlfriends, people you’ve dated, or people you hooked up with.
Remember, your answers are private, and you do not have to answer any questions you do not want
to."
IPVPH1N5 How many of your romantic or sexual partners have ever slapped, punched, shoved, kicked, choked
or otherwise physically hurt you?
8888
Don't Know
7777
Refused to answer
(Range: 0-999)
Skip_21_IPVPH1N5 If BP.1.0. = 1-999, → BP.1.1.. Else, → Intro_IPVSX1N5_21.
Response:

BP.1.1.

IPVPH2N5 During the past 12 months, has a partner slapped, punched, shoved, kicked, choked, or otherwise

physically hurt you?
0
No
1
Yes
8
Don't Know
7
Refused to answer

Topic: Forced Sex (BS)
Response:

BS.1.0

Text2 Intro_IPVSX1N5_21 “Some people experience unwanted sexual situations by strangers or people they know, such as a
partner, friend, teacher, coworker, supervisor, or family member.”
IPVSX1N5_21 How many people have ever threatened or forced you to have vaginal, anal, or oral sex when you
did not want to?
8888
Don't Know
7777
Refused to answer
(Range: 0-999)
Skip_IPVSX1N5_21 If BS.1.0 = 1-999, → BS.1.1.. If BS.1.0 = 0 (no), 7777 (refused to answer), or 8888 (don't know), →
B.0.a..
Response:

BS.1.1.

IPVSX2N5 During the past 12 months, have you been threatened or forced to have vaginal, anal, or oral sex

when you did not want to?
0
No
1
Yes
8
Don't Know
7
Refused to answer
B.0.a.
Calculation_ENIPVN5 ENIPVN5 = Current time

BP.1.0. – B.0.a.

Page |87

Module: Depression and anxiety (M)
Topic: PHQ-4 screening questions (MD)
M.0.
Calculation_STMNHLN5 STMNHLN5 = Current time

Response:

MD.1.0

Text2Intro_21_ANXDEPA8 “Now I’m going to ask you some questions about your mood. When answering, please think about
how often the following has occurred during the past 2 weeks. We’ll use Response Card E for these
questions. We’ll also use the calendar to refer to the past 2 weeks.”
Text2 Intro_ANXDEPA8 “Over the past 2 weeks, how often have you been bothered by any of the following problems?”
ANXDEPA8 Little interest or pleasure in doing things? [USE RESPONSE CARD. SELECT ONLY ONE.]
0
Not at all
1
Several days
2
More than half the days
3
Nearly every day
8
Don't Know
7
Refused to answer
Response:

MD.2.0

ANXDEPB8 Feeling down, depressed, or hopeless? [USE RESPONSE CARD. SELECT ONLY ONE.]

0
1
2
3
8
7

Not at all
Several days
More than half the days
Nearly every day
Don't Know
Refused to answer
Response:

MD.3.0

ANXNR_8 Feeling nervous, anxious or on edge? [USE RESPONSE CARD. SELECT ONLY ONE.]

0
1
2
3
8
7

Not at all
Several days
More than half the days
Nearly every day
Don't Know
Refused to answer
Response:

MD.4.0

ANXSW_8 Not being able to stop or control worrying? [USE RESPONSE CARD. SELECT ONLY ONE.]

0
1
2
3
8
7

Not at all
Several days
More than half the days
Nearly every day
Don't Know
Refused to answer

MD.4.0a
Calculation_PHQ2N8 Create a calculated variable where the sum of ANXDEPA8 + ANXDEPB8=PHQ2N8. If the response to

ANXDEPA8 or ANXDEPB8= 7 (refused to answer) or 8 (don’t know), then calculate the response as 0.

M.0. – MD.4.0a

Page |88
MD.4.0b
Calculation_GAD2N8 Create a calculated variable where the sum of ANXNR_8 + ANXSW_8= GAD2N8. If the response to
Skip_Calculation_GAD2N8

ANXNR_8 or ANXSW_8= 7 (refused to answer) or 8 (don’t know), then calculate the response as 0.
If MD.4.0a =>3, → MA.1.0. Else, → Skip_ANXWR_8.

Topic: PHQ-8 depression (MA)
Response:

MA.1.0

ANXDEPC8 Trouble falling or staying asleep, or sleeping too much? [USE RESPONSE CARD. SELECT ONLY ONE.]

0
1
2
3
8
7

Not at all
Several days
More than half the days
Nearly every day
Don't Know
Refused to answer
Response:

MA.2.0

ANXDEPD8 Feeling tired or having little energy? [USE RESPONSE CARD. SELECT ONLY ONE.]

0
1
2
3
8
7

Not at all
Several days
More than half the days
Nearly every day
Don't Know
Refused to answer
Response:

MA.3.0
ANXDEPE8 Poor appetite or overeating? [USE RESPONSE CARD. SELECT ONLY ONE.]

0
1
2
3
8
7

Not at all
Several days
More than half the days
Nearly every day
Don't Know
Refused to answer
Response:

MA.4.0

ANXDEPF8 Feeling bad about yourself—or that you are a failure or have let yourself or your family down? [USE

RESPONSE CARD. SELECT ONLY ONE.]
0
Not at all
1
Several days
2
More than half the days
3
Nearly every day
8
Don't Know
7
Refused to answer

MD.4.0b – MA.4.0

Page |89
Response:

MA.5.0

ANXDEPG8 Trouble concentrating on things, such as reading the newspaper or watching television? [USE

RESPONSE CARD. SELECT ONLY ONE.]
0
Not at all
1
Several days
2
More than half the days
3
Nearly every day
8
Don't Know
7
Refused to answer
Response:

MA.6.0

ANXDEPH8 Moving or speaking so slowly that other people could have noticed, or the opposite—being so

fidgety or restless that you have been moving around a lot more than usual? [USE RESPONSE CARD.
SELECT ONLY ONE.]
0
Not at all
1
Several days
2
More than half the days
3
Nearly every day
8
Don't Know
7
Refused to answer

Topic: GAD-7 anxiety (MG)
Response:

MG.1.0
Skip_ANXWR_8 If MD.4.0b >=3, → MG.1.0. Else, → M.0.a..

ANXWR_8 Worrying too much about different things? [USE RESPONSE CARD. SELECT ONLY ONE.]

0
1
2
3
8
7

Not at all
Several days
More than half the days
Nearly every day
Don't Know
Refused to answer
Response:

MG.2.0
ANXRX_8 Trouble relaxing? [USE RESPONSE CARD. SELECT ONLY ONE.]

0
1
2
3
8
7

Not at all
Several days
More than half the days
Nearly every day
Don't Know
Refused to answer
Response:

MG.3.0

ANXRS_8 Being so restless that it’s hard to sit still? [USE RESPONSE CARD. SELECT ONLY ONE.]

0
1
2
3
8
7

Not at all
Several days
More than half the days
Nearly every day
Don't Know
Refused to answer

MA.5.0 – MG.3.0

Page |90
Response:

MG.4.0

ANXIR_8 Becoming easily annoyed or irritable? [USE RESPONSE CARD. SELECT ONLY ONE.]

0
1
2
3
8
7

Not at all
Several days
More than half the days
Nearly every day
Don't Know
Refused to answer
Response:

MG.5.0

ANXAF_8 Feeling afraid as if something awful might happen? [USE RESPONSE CARD. SELECT ONLY ONE.]

0
1
2
3
8
7

Not at all
Several days
More than half the days
Nearly every day
Don't Know
Refused to answer

M.0.a.
Calculation_ENMNHLN5 ENMNHLN5 = Current time

MG.4.0 – M.0.a.

Page |91

Module: Alcohol, smoking, and drug use (U)
Topic: Alcohol use (UA)
Response:

UA.1.0.

Text2 Intro_8_ALCOHO_9 “These next questions are about drinking alcohol. Included are beer, wine, wine coolers, and liquor,
such as whiskey or gin, and any other type of alcohol. We will use Response Card F.”
ALCOHO_9 During the past 12 months, how often did you drink alcohol? [USE RESPONSE CARD. SELECT ONLY
ONE.]
1
Daily
2
Weekly
3
Monthly
4
Less than monthly
5
Never
8
Don't Know
7
Refused to answer
Skip_24_ALCOHO_9 If UA.1.0. is 5 (never), 7 (refused to answer), or 8 (don’t know), then → Intro_24_CIGEVRN5. Else →
Intro_8_DRINK_9.
Response:

UA.2.0.
Text2

Intro_8_DRINK_9 “We’ll use the Alcohol Response Card for the next questions. For these questions a drink of alcohol is a

12 oz. beer, a 5 oz. glass of wine, or a 1.5 oz. shot of liquor. We'll use the calendar to refer to the past
30 days.”
DRINK_9 During the past 30 days, on how many days did you have an alcoholic drink?
88
Don't Know
77
Refused to answer
(Range: 0–30)
Skip_24_DRINK_9 If UA.2.0. is 0, 77 (refused to answer), or 88 (don’t know), then → Intro_24_CIGEVRN5. Else → UA.3.0..
Response:

UA.3.0.

NDRINK_9 During the past 30 days, how many alcoholic drinks did you have on a typical day when you were

drinking?
88
Don't Know
77
Refused to answer
(Range: 1-100)
UA.4.0.

Response:
BINGE_8 During the past 30 days, on how many days did you have [5 or 4] or more alcoholic drinks in one

sitting?
88
Don't Know
77
Refused to answer
(Range: 0-30)
If MFSEXN25 = 2 (female), then read, “During the past 30 days, on how many days did you have 4
or more alcoholic drinks in one sitting?” If MFSEXN25 = 1 (male), 7 (refused), or 8 (don’t know),
then read, “During the past 30 days, on how many days did you have 5 or more alcoholic drinks in
one sitting?” The same tokens apply to Hard_edit_BINGE_8.
If UA.4.0. > UA.2.0., then read, “The number of days that you had any drink should be equal to or
larger than the number of days you had [5 or 4] or more drinks.” Return to UA.2.0..

UA.1.0. – UA.4.0.

Page |92

Topic: Smoking and vaping (US)
US.1.0.

Response:

Text2 Intro_24_CIGEVRN5 “The next questions are about smoking cigarettes or other tobacco products.”
CIGEVRN5 Have you smoked at least 100 cigarettes, equal to 5 packs of cigarettes, in your entire life?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_CIGEVRN5 If US.1.0. is 0 (no), 7 (refused to answer), or 8 (don’t know), then → US.2.0.. Else, → Intro_CIG_OFT.
Response:

US.1.1.
Text2

Intro_CIG_OFT “Now we will use Response Card F.”
CIG_OFT How often do you smoke cigarettes now? [USE RESPONSE CARD. SELECT ONLY ONE.]

1
2
3
4
5
8
7

Daily
Weekly
Monthly
Less than monthly
Never
Don't Know
Refused to answer
Response:

US.2.0.

CIGARN5 Have you smoked cigars, cigarillos, or little filtered cigars at least 50 times in your entire life?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_CIGARN5 If US.2.0. is 0 (no), 7 (refused to answer), or 8 (don’t know), then → Skip_CIG_QTN5. Else, → US.2.1..
Response:

US.2.1.

CIGARFN5 Do you now smoke cigars, cigarillos, or little filtered cigars every day, some days, rarely, or not at

all? [SELECT ONE RESPONSE.]
1
Every day
2
Some days
3
Rarely
4
Not at all
8
Don't Know
7
Refused to answer
US.3.0.
Text2
Text2

Response:
Skip_CIG_QTN5 If US.1.1. = 1 (Daily), 2 (Weekly), 3 (Monthly), or 4 (Less than monthly) or if US.2.1. = 1 (every day), 2

(some days), or 3 (rarely), → Intro_CIG_QTN5. Else, → Intro_CIGELCN5_21.
Intro_CIG_QTN5 “The next questions ask about quitting smoking. By smoking, I mean smoking cigarettes, cigars,
cigarillos, or little filtered cigars.”
CIG_QTN5 During the past 12 months, have you stopped smoking for one day or longer because you were
trying to quit?
0
No
1
Yes
8
Don't Know
7
Refused to answer
US.1.0. – US.3.0.

Page |93
Response:

US.4.0.

CIG_DQ_8 During the past 12 months, has a doctor, nurse, or other healthcare worker advised you to quit

smoking?
0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

US.5.0.

Text2 Intro_CIGELCN5_21 "The next questions are about vaping e-cigarettes or other vaping devices. People can vape nicotine,
tobacco, marijuana, flavoring or other substances."
CIGELCN5_21 Have you ever, even once, vaped anything with an e-cigarette or other vaping device?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_CIGELCN5_21 If US.5.0. is 1 (yes), → Intro_VAPE_TOBACCON21. Else if US.5.0. is 0 (No) or 8 (Don't know) or 7
(Refused to Answer), → INTRO_21_MARIJU_9.
Response:

US.5.1.
Intro_VAPE_TOBACCON21
Text2
"During the past 30 days, have you vaped any of the following:"
VAPE_TOBACCON21 Tobacco or nicotine?

0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

US.5.2.

VAPE_MARIJN21 Marijuana, including marijuana concentrates, marijuana waxes, THC or hash oils?

0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

US.5.3.
VAPE_OTHERN21 Any other substances?

0
1
8
7

No
Yes
Don't know
Refused to answer

US.4.0. – US.5.3.

Page |94

Topic: Non-injection drug use (UN)
UN.1.0.

Response:

Text2 Intro_21_MARIJU_9 “I’m going to read you a list of drugs. For each drug I mention, please tell me how often you used it
during the past 12 months. Don’t include drugs you injected or drugs that were used for medical
purposes. We’ll use Response Card F for these questions.”
MARIJU_9 During the past 12 months, how often did you use marijuana? [USE RESPONSE CARD. SELECT ONLY
ONE.]
1
Daily
2
Weekly
3
Monthly
4
Less than monthly
5
Never
8
Don't Know
7
Refused to answer
Response:

UN.2.0.

CRACK1_9 During the past 12 months, how often did you use crack? [USE RESPONSE CARD. SELECT ONLY ONE.]

1
2
3
4
5
8
7

Daily
Weekly
Monthly
Less than monthly
Never
Don't Know
Refused to answer
Response:

UN.3.0.

COCSMO_9 During the past 12 months, how often did you use cocaine that is smoked or snorted? [USE

RESPONSE CARD. SELECT ONLY ONE.]
1
Daily
2
Weekly
3
Monthly
4
Less than monthly
5
Never
8
Don't Know
7
Refused to answer
Response:

UN.4.0.

METHN5 During the past 12 months, how often did you use any methamphetamines, such as crystal meth,

tina, crank, or ice? [USE RESPONSE CARD. SELECT ONLY ONE.]
1
Daily
2
Weekly
3
Monthly
4
Less than monthly
5
Never
8
Don't Know
7
Refused to answer

UN.1.0. – UN.4.0.

Page |95
Response:

UN.5.0.

CLUBN5 During the past 12 months, how often did you use club drugs such as Ecstasy (also called X),

ketamine (also called Special K), or GHB (also called Liquid Ecstasy)? [USE RESPONSE CARD. SELECT
ONLY ONE.]
1
Daily
2
Weekly
3
Monthly
4
Less than monthly
5
Never
8
Don't Know
7
Refused to answer
Response:

UN.6.0.

POPPER_9 During the past 12 months, how often did you use poppers, also called amyl nitrite? [USE RESPONSE

CARD. SELECT ONLY ONE.]
1
Daily
2
Weekly
3
Monthly
4
Less than monthly
5
Never
8
Don't Know
7
Refused to answer
Response:

UN.7.0.

HEROIN_9 During the past 12 months, how often did you use heroin or opium that is smoked or snorted? [USE

RESPONSE CARD. SELECT ONLY ONE.]
1
Daily
2
Weekly
3
Monthly
4
Less than monthly
5
Never
8
Don't Know
7
Refused to answer
UN.8.0.

Response:
PAINKN5_21 Next, I’ll ask about prescription pain relievers such as oxycodone, hydrocodone, Percocet, or

Vicodin. During the past 12 months, how often did you take a prescription pain reliever that was not
prescribed to you or was prescribed to you, but you took more than directed? [USE RESPONSE
CARD. SELECT ONLY ONE.]
1
Daily
2
Weekly
3
Monthly
4
Less than monthly
5
Never
8
Don't Know
7
Refused to answer

UN.5.0. – UN.8.0.

Page |96
Response:

UN.9.0.

TRANQN5_21 I am going to ask you about prescription tranquilizers such as Valium, Ativan, Xanax, or downers.

During the past 12 months, how often did you take a prescription tranquilizer that was not
prescribed to you, or was prescribed to you but you took more than directed? [USE RESPONSE
CARD. SELECT ONLY ONE.]
1
Daily
2
Weekly
3
Monthly
4
Less than monthly
5
Never
8
Don't know
7
Refused to answer
Response:

UN.10.0.

OTHERDRUGN21 During the past 12 months, did you use any other drug? Remember, don’t include drugs you

injected or drugs that were used for medical purposes.
0
No
1
Yes
8
Don't Know
7
Refused to answer

Topic: Injection drug use (UI)
Response:

UI.1.0.
Text2

Intro_EVRINJN5 “The next questions are about injection drug use. This means injecting drugs yourself or having

someone else inject you.”
EVRINJN5 Have you ever shot up or injected any drugs that weren’t used for medical purposes? By shooting

up, I mean anytime a needle was used to inject drugs in your veins, under the skin, or in the muscle.
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_EVRINJN5 If UI.1.0. is 1 (yes), → UI.1.1.. Else, → U.0.a..
Response:

UI.1.1.

INJECTN5 During the past 12 months, have you shot up or injected any drugs that weren’t used for medical

purposes?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_INJECTN5 If UI.1.1. is 1 (yes) then → Intro_COCINJN5. Else, → next topic U.0.a..

UN.9.0. – UI.1.1.

Page |97
Response:

UI.2.0.
Text2

Intro_COCINJN5 “Now I'm going to read you a list of drugs. For each drug I mention, please tell me how often you

injected it during the past 12 months. We’ll use Response Card F for these questions.”
COCINJN5 During the past 12 months, how often did you inject powder cocaine? [USE RESPONSE CARD.

SELECT ONLY ONE.]
1
Daily
2
Weekly
3
Monthly
4
Less than monthly
5
Never
8
Don't Know
7
Refused to answer
Response:

UI.3.0.

HERINJN5 During the past 12 months, how often did you inject heroin? [USE RESPONSE CARD. SELECT ONLY

ONE.]
1
2
3
4
5
8
7

Daily
Weekly
Monthly
Less than monthly
Never
Don't Know
Refused to answer
Response:

UI.4.0.

SPDBALN5 During the past 12 months, how often did you inject heroin and cocaine together, also called

speedball? [USE RESPONSE CARD. SELECT ONLY ONE.]
1
Daily
2
Weekly
3
Monthly
4
Less than monthly
5
Never
8
Don't Know
7
Refused to answer
Response:

UI.5.0.

METINJN5 During the past 12 months, how often did you inject methamphetamines, such as crystal meth, tina,

crank or ice? [USE RESPONSE CARD. SELECT ONLY ONE.]
1
Daily
2
Weekly
3
Monthly
4
Less than monthly
5
Never
8
Don't Know
7
Refused to answer

UI.2.0. – UI.5.0.

Page |98
Response:

UI.6.0.

PKINJN5_21 During the past 12 months, how often did you inject painkillers, such as oxycodone, hydrocodone,

Percocet, or Vicodin? [USE RESPONSE CARD. SELECT ONLY ONE.]
1
Daily
2
Weekly
3
Monthly
4
Less than monthly
5
Never
8
Don't Know
7
Refused to answer
If UI.1.1. is 1 (yes) and [UI.2.0., UI.3.0., UI.4.0., UI.5.0., or UI.6.0.] are all 5 (Never), then display: The
respondent said that they didn’t inject any of the specific drugs that you asked about. Verify that the
respondent injected drugs during the past 12 months. Allow the program to move forward.
Response:

UI.7.0.
Text2

Intro_SHRNDLN5 “Now I am going to ask you some questions about sharing needles and other injection equipment.

When I ask you about needles, I’m talking about needles and syringes.”
SHRNDLN5 When you injected during the past 12 months, did someone use the same needle after you used it
to either inject drugs or divide drugs?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Response:

UI.8.0.

SHR_WRKS When you injected during the past 12 months, did someone use the same cookers, cotton, or rinse

water after you used it?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Response:

UI.9.0.
Text2

Intro_GETNDAN5 “During the past 12 months when you injected, did you get your needles at any of the following

places:”
GETNDAN5 A needle exchange program?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

UI.9.1.
GETNDBN5 A pharmacy or drug store?

0
1
8
7

No
Yes
Don't Know
Refused to answer

UI.6.0. – UI.9.1.

Page |99
Response:

UI.9.2.
GETNDCN5 A doctor’s office, clinic, or hospital?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

UI.9.3.
GETNDDN5 A friend, relative, or sex partner?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

UI.9.4.
GETNDEN5 A needle or drug dealer, shooting gallery, or off the street?

0
1
8
7

No
Yes
Don't Know
Refused to answer

U.0.a.
Calculation_ENDRUGN5 ENDRUGN5 = Current time

UI.9.2. – U.0.a.

Page |101

Module: Stigma and discrimination (R)
Topic: Stigma (RS)
Response:

RS.1.0

Text2Intro_21_STGA12N8 "Next, I'll read statements that some people with HIV feel. We want to know if you experience these
feelings. These statements are not things that I or anyone in this project thinks. Remember that you
don't have to answer any question you don't want to. For each statement that I read, tell me how
strongly you disagree or agree. We'll use Response Card G."
STGA12N8 During the past 12 months, I have been hurt by how people reacted to learning I have HIV. [USE
RESPONSE CARD. SELECT ONLY ONE.]
1
Strongly disagree
2
Somewhat disagree
3
Neutral
4
Somewhat agree
5
Strongly agree
8
Don't Know
7
Refused to answer
Response:

RS.2.0

STGB12N8 During the past 12 months, I have stopped socializing with some people because of their reactions

to my HIV status. [USE RESPONSE CARD. SELECT ONLY ONE.]
1
Strongly disagree
2
Somewhat disagree
3
Neutral
4
Somewhat agree
5
Strongly agree
8
Don't Know
7
Refused to answer
Response:

RS.3.0

STGC12N8 During the past 12 months, I have lost friends by telling them I have HIV. [USE RESPONSE CARD.

SELECT ONLY ONE.]
1
Strongly disagree
2
Somewhat disagree
3
Neutral
4
Somewhat agree
5
Strongly agree
8
Don't Know
7
Refused to answer
Response:

RS.4.0.

STIGMDN5 I am very careful who I tell that I have HIV. [USE RESPONSE CARD. SELECT ONLY ONE.]

1
2
3
4
5
8
7

Strongly disagree
Somewhat disagree
Neutral
Somewhat agree
Strongly agree
Don't know
Refused to answer

RS.1.0 – RS.4.0.

Page |102
Response:

RS.5.0.

STIGMEN5 I worry that people who know I have HIV will tell others. [USE RESPONSE CARD. SELECT ONLY ONE.]

1
2
3
4
5
8
7

Strongly disagree
Somewhat disagree
Neutral
Somewhat agree
Strongly agree
Don't know
Refused to answer
Response:

RS.6.0.

STIGMFN5 I feel that I am not as good a person as others because I have HIV. [USE RESPONSE CARD. SELECT

ONLY ONE.]
1
2
3
4
5
8
7

Strongly disagree
Somewhat disagree
Neutral
Somewhat agree
Strongly agree
Don't know
Refused to answer
Response:

RS.7.0.

STIGMGN5 Having HIV makes me feel unclean. [USE RESPONSE CARD. SELECT ONLY ONE.]

1
2
3
4
5
8
7

Strongly disagree
Somewhat disagree
Neutral
Somewhat agree
Strongly agree
Don't know
Refused to answer
Response:

RS.8.0.

STIGMHN5 Having HIV makes me feel that I’m a bad person. [USE RESPONSE CARD. SELECT ONLY ONE.]

1
2
3
4
5
8
7

Strongly disagree
Somewhat disagree
Neutral
Somewhat agree
Strongly agree
Don't know
Refused to answer
Response:

RS.9.0.

STIGMIN5 Most people think that a person with HIV is disgusting. [USE RESPONSE CARD. SELECT ONLY ONE.]

1
2
3
4
5
8
7

Strongly disagree
Somewhat disagree
Neutral
Somewhat agree
Strongly agree
Don't know
Refused to answer

RS.5.0. – RS.9.0.

Page |103
Response:

RS.10.0.

STIGMJN5 Most people with HIV are rejected when others find out. [USE RESPONSE CARD. SELECT ONLY ONE.]

1
2
3
4
5
8
7

Strongly disagree
Somewhat disagree
Neutral
Somewhat agree
Strongly agree
Don't know
Refused to answer

Topic: Discrimination (RD)
Response:

RD.1.1.
Text2

Intro_DISC1N24 During the past 12 months, did any of the following things happen to you because someone knew or

suspected that you have HIV?  
DISC1N24 You were ignored, excluded, or avoided by people close to you

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

RD.1.2.
DISC2N24 You were rejected by a potential sexual or romantic partner

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

RD.1.3.
DISC3N24 You were denied a job, or you lost a job

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

RD.1.4
DISC4N24 You were treated with hostility or coldness by strangers

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

RD.1.5.
DISC5N24 Someone acted as if you could not be trusted

0
1
8
7

No
Yes
Don't Know
Refused to answer

RS.10.0. – RD.1.5.

Page |104
Response:

RD.1.6.
DISC6N24 Someone insulted or made fun of you

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

RD.1.7.
DISC7N24 You were denied a place to live or lost a place to live

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

RD.1.8.
DISC8N24 Your personal property was damaged or stolen

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

RD.1.9.
DISC9N24 You were physically assaulted or beaten up

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

RD.1.10.

DISC10N24 You were treated poorly or made to feel inferior when receiving health care

0
1
8
7

No
Yes
Don't Know
Refused to answer

R.0.a.
Calculation_ENSTIGN5 ENSTIGN5 = Current time

RD.1.6. – R.0.a.

Page |105

Module: Gynecological and reproductive history (G)
Topic: Gynecological care (GH)
G.0.
Calculation_STOBGYN5 STOBGYN5 = current time

Response:

GH.1.0.

Text2 Skip_21_PLV_EX_9 If ST.1.0. = 2 (female), then → Intro_PLV_EX_9. If ST.1.0. = 1 (male) → Skip_INTENTDADN21.
“I’m now going to ask some questions about pelvic exams and Pap smears. A pelvic exam is a vaginal
Intro_PLV_EX_9 examination. A Pap smear, also called a cervical cancer test or Pap test, is a test used to check for
Text2
cancer of the cervix. Often a pelvic exam and Pap smear are performed at the same time.”
PLV_EX_9 During the past 12 months, have you had a pelvic examination?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

GH.2.0.

PAP_EX_8 [During the past 3 years or Since testing positive for HIV], have you had a Pap smear?

0
No
1
Yes
8
Don't Know
7
Refused to answer
If POS1S_9 <3 years prior to interview date, 8888 (don't know), or 7777 (refused to answer), then
question should read, "Since testing positive for HIV, have you had a Pap smear?" If POS1S_9 >=3
years ago or POS1S_9 = Skipped, then question should read as "During the past 3 years, have you had
a Pap smear?"
Response:

GH.3.0.
POSTMEN8 Are you post-menopausal, meaning you don’t have periods anymore?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

GH.4.0.
TUBLIGN8 Have you had a tubal ligation, also known as having your “tubes tied”?

0
1
8
7

No
Yes
Don't know
Refused to answer

G.0. – GH.4.0.

Page |106
Response:

GH.5.0

HYSTERN8 Have you had a hysterectomy? A hysterectomy is when all or some of your uterus is removed.

No
0
1
Yes
8
Don't Know
7
Refused to answer
Skip_21_HYSTERN8 If GH.3.0. is 1 (yes) or GH.4.0. is 1 (yes) or GH.5.0 is 1 (yes), then → Intro_N21_PREG_21 (Number of
times pregnant). If GH.3.0. is 0 (no), 7 (refused to answer) or 8 (don’t know) and GH.4.0. is 0 (no), 7
(refused to answer) or 8 (don’t know) and GH.5.0 is 0 (no), 7 (refused to answer) or 8 (don’t know), →
Skip_INTENTDADN21.

Topic: Family planning (GF)
Response:

GF.1.0.

Text2Skip_INTENTDADN21 If ST.1.0. = 2 (female) and ST.3.0. = 0, 777 (refused to answer) or 888 (don’t know), → Intro_N21
_PREG_21. If ST.1.0. = 2 (female) and ST.3.0. >=1, → GF.2.0.. If ST.1.0. = 1 (male), →
Intro_INTENTDADN21.
Intro_INTENTDADN21 "Now I’m going to ask you about becoming a biological father."
Text2
INTENTDADN21 At any time during the past 12 months, have you tried to become a biological father?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip2_INTENTDADN21 If GF.1.0. = 0 (no) → GF.6.0.. If GF.1.0. = 1 (yes), → GF.4.0.. If GF.1.0. is 7 (refused to answer) or 8
(don’t know), → Calcual^on_ENOBGYN5.
Response:

GF.2.0.
PREGNOWN21 Are you currently pregnant?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

GF.3.0.
INTENTN8_21 At any time during the past 12 months, have you tried to get pregnant?

0
No
1
Yes
8
Don't Know
7
Refused to answer
If PREGNOWN21 = 1 (yes), then display question as, “Were you trying to get pregnant?”
Skip_INTENTN8_21 If GF.3.0. = 1 (yes), → GF.4.0.. If GF.3.0. = 0 (no), 7 (refused to answer), or 8 (don’t know), → GF.5.0..
Response:

GF.4.0.

KIDTALKN21 During the past 12 months, has a doctor, nurse, or other healthcare worker talked with you about

your desire to have children?
0
No
1
Yes
8
Don’t Know
7
Refused to answer
Skip_KIDTALKN21 If ST.1.0. = 1 (male), → G.0.a.. If ST.1.0. = 2 (female), → GF.5.0..
GH.5.0 – GF.4.0.

Page |107
Response:

GF.5.0.

NOPREGN21 Some things women do to prevent pregnancy include using birth control pills or condoms. At any

time during the past 12 months, have you tried to prevent getting pregnant?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_NOPREGN21 If GF.5.0. = 1 (yes) → GF.6.0.. If GF.5.0. = 0 (no), 7 (refused to answer) or 8 (don’t know), →
Skip_VERTRANN21.
Response:

GF.6.0.

Skip_PREGTALKN21 If ST.1.0. = 1 (male) AND ST.2.0. ≥ 1, → GF.6.0.. If ST.1.0. = 1 (male) and ST.2.0. = 0, 7777 (refused to

answer) or 8888 (don’t know), → G.0.a..
PREGTALKN21 During the past 12 months, has a doctor, nurse, or other healthcare worker talked with you about

how to prevent pregnancy?
0
No
1
Yes
8
Don't Know
7
Refused to answer
INTENTDADN21 = 0 (no), then question should read, “Some things men do to prevent getting
someone pregnant include using condoms or getting a vasectomy. During the past 12 months, has a
doctor, nurse, or other healthcare worker talked with you about doing anything to prevent getting
someone pregnant?”
Response:

GF.7.0.

Skip_VERTRANN21 If GF.2.0. = 1 (yes) or GF.3.0. = 1 (yes), → GF.7.0.. If GF.3.0. = 0 (no) or 7 (refused) or 8 (don’t know), →

Intro_N21_PREG_21 (Number of ^mes pregnant). If GF.2.0. = 0 (no) or 7 (refused) or 8 (don’t know), →
Intro_N21_PREG_21 (Number of ^mes pregnant). If ST.1.0. = 1 (male) → G.0.a..
VERTRANN21 During the past 12 months, has a doctor, nurse, or other healthcare worker talked with you about

how to prevent passing HIV on to your baby?
0
No
1
Yes
8
Don’t know
7
Refused to answer

GF.5.0. – GF.7.0.

Page |108

Topic: Reproductive history (GR)
GR.1.0.

Response:

Text2Intro_N21_PREG_21 "Now I’m going to ask about pregnancies you may have had since testing positive for HIV. These
pregnancies could have resulted in a live birth, miscarriage, abortion, stillbirth, or ectopic pregnancy."
PREG_21 Since testing positive for HIV in [INSERT POS1S_9 (date of first positive test)], how many times have
you been pregnant?
888
Don't Know
777
Refused to answer
(Range: 0-100)
If POS1S_9 is 77/7777 (refused to answer), 88/8888 (don’t know) or Skipped and PREGNOWN21 = 1
(yes), then PREG_21 should read as follows: "Since testing positive for HIV, how many times have you
been pregnant? Don’t count your current pregnancy.”
If PREGNOWN21 = 1 (yes) then PREG_21 should read as follows: “Since testing positive for HIV in
[INSERT POS1S_9], how many times have you been pregnant? Don’t count your current pregnancy.”
If POS1S_9 is 77/7777 (refused to answer), 88/8888 (don’t know) or Skipped, then PREG_21 should
read as follows: "Since testing positive for HIV, how many times have you been pregnant?"
Skip_PREG_21 If GF.2.0. = 1 (yes) AND GR.1.0. = 0, then → G.0.a.. If GR.1.0. = 0, 777 (refused to answer) or 888
(don’t know), → G.0.a.. If GR.1.0. >= 1, → Skip_OUTCM1N3_21.
Response:

GR.2.0.
Skip_OUTCM1N3_21 If GR.1.0. = 1, → GR.2.0.. If GR.1.0. > 1, → GR.3.0..

OUTCM1N3_21 What was the outcome of this pregnancy? [READ RESPONSES. SELECT ONLY ONE.]

1
Live birth
2
Miscarriage
3
Abortion
4
Stillbirth
5
Ectopic pregnancy
8
Don’t know
7
Refused to answer
Skip2_OUTCM1N3_21 If GR.2.0. = 1 (Live birth), then → GR.8.0.. If GR.2.0. is 8 (don’t know) or 7 (refused to answer), →
G.0.a.. Else, → G.0.a..
Response:

GR.3.0.
OUTCM1N21 How many of these pregnancies resulted in a live birth?

888
Don’t know
777
Refused to answer
(Range: 0-100)
If GR.3.0. > GR.1.0., display the following message: "This does not add up with the number you gave
me earlier." Do not allow the program to advance.
Skip_OUTCM1N21 If GR.1.0. = GR.3.0., → GR.9.0.. If GR.3.0. is 888 (don’t know) or 777 (Refused to answer), → GR.4.0..
Else, → GR.4.0..

GR.1.0. – GR.3.0.

Page |109
Response:

GR.4.0.
OUTCM2N21 How many of these pregnancies resulted in a miscarriage?

888
Don’t know
777
Refused to answer
(Range: 0-100)
If GR.3.0. + GR.4.0. > GR.1.0., display the following message: “This does not add up with the number
you gave me earlier”. Do not allow the program to advance.
Skip_OUTCM2N21 If GR.1.0. = GR.4.0. and GR.3.0. = 0, → G.0.a.. If GR.1.0. = GR.3.0. + GR.4.0., then → Skip_KID1HVN3_
21. If GR.4.0. is 888 (don’t know) or 777 (refused to answer), → GR.5.0.. Else, → GR.5.0..
Response:

GR.5.0.
OUTCM3N21 How many of these pregnancies resulted in an abortion?

888
Don’t know
777
Refused to answer
(Range: 0-100)
If GR.3.0. + GR.4.0. + GR.5.0. > GR.1.0., display the following message: “This does not add up with the
number you gave me earlier”. Do not allow the program to advance.
Skip_OUTCM3N21 If GR.1.0. = GR.5.0. and GR.3.0. + GR.4.0. = 0, → G.0.a.. If GR.1.0. = GR.3.0. + GR.4.0. + GR.5.0., then →
Skip_KID1HVN3_21. If GR.5.0. = 888 (don’t know) or 777 (refused to answer), → GR.6.0.. Else, →
GR.6.0..
Response:

GR.6.0.
OUTCM4N21 How many of these pregnancies resulted in a stillbirth?

888
Don’t know
777
Refused to answer
(Range: 0-100)
If GR.3.0. + GR.4.0. + GR.5.0. + GR.6.0. > GR.1.0., display the following message: “This does not add up
with the number you gave me earlier”. Do not allow the program to advance.
Skip_OUTCM4N21 If GR.1.0. = GR.6.0. and GR.3.0. + GR.4.0. + GR.5.0. = 0, → G.0.a.. If GR.1.0. = GR.3.0. + GR.4.0. + GR.5.0.
+ GR.6.0., then → Skip_KID1HVN3_21. If GR.6.0. is 777 (refused to answer) or 888 (don’t know), →
GR.7.0.. Else, → GR.7.0..
Response:

GR.7.0.
OUTCM5N21 How many of these pregnancies resulted in an ectopic pregnancy?

888
Don’t know
777
Refused to answer
(Range: 0-100)
If GR.1.0. does not equal GR.3.0. + GR.4.0. + GR.5.0. + GR.6.0. + GR.7.0., then display “The number of
pregnancy outcomes does not add up to the number of pregnancies.” Allow the program to move
forward.
If GR.3.0. + GR.4.0. + GR.5.0. + GR.6.0. + GR.7.0. > GR.1.0., display the following message: “This does
not add up with the number you gave me earlier”. Do not allow the program to advance.
Skip_OUTCM5N21 If GR.1.0. = GR.7.0. and GR.3.0. + GR.4.0. + GR.5.0. + GR.6.0. = 0, → G.0.a.. If GR.7.0. is 777 (refused to
answer) or 888 (don’t know), → Skip_KID1HVN3_21. Else, → Skip_KID1HVN3_21.

GR.4.0. – GR.7.0.

Page |110
Response:

GR.8.0.
Skip_KID1HVN3_21 If GR.3.0. = 1, then → GR.8.0.. If GR.3.0. > 1, then → GR.9.0..

Else, → G.0.a..
KID1HVN3_21 Was the child diagnosed with HIV?

0
No
1
Yes
2
Indeterminate
8
Don’t know
7
Refused to answer
Skip2_KID1HVN3_21 All responses → G.0.a..
Response:

GR.9.0.
KIDHIVN21 How many of your biological children were born with HIV?

888
Don’t know
777
Refused to answer
(Range: 0-100)
GR.9.0. must be ≤ GR.3.0.. If GR.9.0. > GR.3.0. then read, “Earlier you said that you had [GR.3.0.] live
births, but the number you just gave me is greater than that.” Do not allow the program to advance.
G.0.a.
Calculation_ENOBGYN5 ENOBGYN5 = Current time

GR.8.0. – G.0.a.

Page |111

Module: Met and unmet needs (N)
Topic: Services and assistance programs (ND)
Response:

ND.1.0.

Text2 Intro_8_CSMNA_5 “For these next questions, I’m going to ask about services you used or needed during the past 12
months.First, I'll ask whether you got the service, and if you didn’t, I'll ask whether you needed it.
These questions might sound similar, but I need to ask you all of them.”
CSMNA_5 The first question is about HIV case management services. A case manager is a professional who
helps you to get care and other services that you or your family may need. During the past 12
months, did you get HIV case management services?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_6_CSMNA_5 If ND.1.0. is 0 (no), 7 (refused to answer), or 8 (don’t know), → ND.1.1.. Else, → Skip1_6_TKMDA_5.
Response:

ND.1.1.

CSMNB_5 During the past 12 months, have you needed HIV case management services?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_24_CSMNB_5 If ND.1.1. is 1 (yes), → CSMNCN24. Else, → Skip1_6_TKMDA_5.
Response:

ND.1.2.
CSMNCN24 Did you know this service existed?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_CSMNCN24 If CSMNCN24 is 1 (yes), → CSMNDN24. Else, → Skip1_6_TKMDA_5.
Response:

ND.1.3.
CSMNDN24 Did you know how to get this service?

0
1
8
7
ND.2.0.

No
Yes
Don't Know
Refused to answer
Response:

Skip1_6_TKMDA_5 If TC.1.0. = 1 (yes) or TC.2.0. = 1 (yes), then → ND.2.0.. Else, → Skip_NEDADA_5.

TKMDA_5 During the past 12 months, did you get professional help on how to take your HIV medicines on

time or correctly?
0
No
1
Yes
8
Don't know
7
Refused to answer
Skip2_6_TKMDA_5 If ND.2.0. is 0 (no), 7 (refused to answer), or 8 (don’t know), → ND.2.1.. Else, → Skip_NEDADA_5.

ND.1.0. – ND.2.0.

Page |112
Response:

ND.2.1.

TKMDB_5 During the past 12 months, have you needed professional help on how to take your HIV medicines

on time or correctly?
0
No
1
Yes
8
Don't know
7
Refused to answer
Skip_24_TKMDB_5 If ND.2.1. is 1 (yes), → ND.2.2. Else, → Skip_NEDADA_5.
Response:

ND.2.2
TKMDCN24 Did you know this service existed?

0
No
1
Yes
8
Don't know
7
Refused to answer
Skip_TKMDCN24 If ND.2.2 is 1 (yes), → TKMDDN24. Else, → Skip_NEDADA_5.
Response:

ND.2.3.
TKMDDN24 Did you know how to get this service?

0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

ND.3.1.
Skip_NEDADA_5 If FH.1.6. is 0 (no), → ND.3.1.. Else, → Intro_PATNAVN5.

NEDADA_5 Earlier you told me that during the past 12 months you did not have Ryan White or ADAP coverage.

During the past 12 months, have you needed to get medicine through ADAP?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip2_24_NEDADA_5 If ND.3.1. is 1 (yes), → ADAPCN24. Else, → Intro_PATNAVN5.
Response:

ND.3.2.
ADAPCN24 Did you know this service existed?

0
No
1
Yes
8
Don't know
7
Refused to answer
Skip_ADAPCN24 If ADAPCN24 is 1 (yes), → ADAPDN24. Else, → Intro_PATNAVN5.
Response:

ND.3.3.
ADAPDN24 Did you know how to get this service?

0
1
8
7

No
Yes
Don't know
Refused to answer
ND.2.1. – ND.3.3.

Page |113
Response:

ND.4.0.

Intro_PATNAVN5 “The next question is about patient navigation services. This is someone whose job it is to help you get

Text2

the best medical care for you. For example, a patient navigator might help you talk to your doctor
about your care or go with you to your medical appointments.”
PATNAVN5 During the past 12 months, did you get patient navigation services?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_PATNAVN5 If ND.4.0. is 0 (no), 7 (refused to answer), or 8 (don’t know), → ND.4.1.. Else, → ND.5.0..
Response:

ND.4.1.

PATNABN5 During the past 12 months, have you needed patient navigation services?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_24_PATNABN5 If ND.4.1. is 1 (yes), → PATNACN24. Else, → ND.5.0..
Response:

ND.4.2
PATNACN24 Did you know this service existed?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_PATNACN24 If PATNACN24 is 1 (yes), → PATNADN24. Else, → ND.5.0..
Response:

ND.4.3.
PATNADN24 Did you know how to get this service?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

ND.5.0.
GET_GRP During the past 12 months, did you get HIV peer group support?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_GET_GRP If ND.5.0. is 0 (no), 7 (refused to answer), or 8 (don’t know), → ND.5.1.. Else, → ND.6.0..
Response:

ND.5.1.
NED_GRP During the past 12 months, have you needed HIV peer group support?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_24_NED_GRP If ND.5.1. is 1 (yes), → GRPSCN24. Else, → ND.6.0..
ND.4.0. – ND.5.1.

Page |114
Response:

ND.5.2.
GRPSCN24 Did you know this service existed?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_GRPSCN24 If GRPSCN24 is 1 (yes), → GRPSDN24. Else, → ND.6.0..
Response:

ND.5.3.
GRPSDN24 Did you know how to get this service?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

ND.6.0.
DENS12_9 During the past 12 months, did you get dental care?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_DENS12_9 If ND.6.0. is 0 (no), 7 (refused to answer), or 8 (don’t know), → ND.6.1.. Else, → ND.7.0..
Response:

ND.6.1.
DENSER_9 During the past 12 months, have you needed dental care?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_24_DENSER_9 If ND.6.1. is 1 (yes), → DENSCN24. Else, → ND.7.0..
Response:

ND.6.2.
DENSCN24 Did you know this service existed?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_ DENSCN24 If DENSCN24 is 1 (yes), → DENSDN24. Else, → ND.7.0..
Response:

ND.6.3.
DENSDN24 Did you know how to get this service?

0
1
8
7

No
Yes
Don't Know
Refused to answer

ND.5.2. – ND.6.3.

Page |115
Response:

ND.7.0.

GET_SUBU During the past 12 months, did you get drug or alcohol counseling or treatment?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_GET_SUBU If ND.7.0. is 0 (no), 7 (refused to answer), or 8 (don’t know), → ND.7.1.. Else, → ND.8.0..
Response:

ND.7.1.

NED_SUBU During the past 12 months, have you needed drug or alcohol counseling or treatment?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_24_NED_SUBU If ND.7.1. is 1 (yes), → SUBUCN24. Else, → ND.8.0..
Response:

ND.7.2.
SUBUCN24 Did you know this service existed?

0
No
1
Yes
8
Don't know
7
Refused to answer
Skip_SUBUCN24 If SUBUCN24 is 1 (yes), → SUBUDN24. Else, → ND.8.0..
Response:

ND.7.3.
SUBUDN24 Did you know how to get this service?

0
1
8
7

No
Yes
Don't know
Refused to answer
Response:

ND.8.0.

MENTA_5 During the past 12 months, have you seen or talked to a mental health professional such as a

psychologist, psychiatrist, psychiatric nurse, or clinical social worker about your health?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_MENTA_5 If ND.8.0. is 0 (no), 7 (refused to answer), or 8 (don’t know), → ND.8.1.. Else, → ND.9.0..
Response:

ND.8.1.

MENTB_5 During the past 12 months, have you needed to see or talk to a mental health professional about

your health?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_24_MENTB_5 If ND.8.1. is 1 (yes), → MENTCN24. Else, → ND.9.0..

ND.7.0. – ND.8.1.

Page |116
Response:

ND.8.2.
MENTCN24 Did you know this service existed?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_MENTCN24 If MENTCN24 is 1 (yes), → MENTDN24. Else, → ND.9.0..
Response:

ND.8.3.
MENTDN24 Did you know how to get this service?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

ND.9.0.
TRAS12_9 During the past 12 months, did you get transportation assistance?

0
No
1
Yes
8
Don't know
7
Refused to answer
Skip_TRAS12_9 If ND.9.0. is 0 (no), 7 (refused to answer), or 8 (don’t know), → ND.9.1.. Else, → ND.10.0..
Response:

ND.9.1.
TRASAS_9 During the past 12 months, have you needed transportation assistance?

0
No
1
Yes
8
Don't know
7
Refused to answer
Skip_24_TRASAS_9 If ND.9.1. is 1 (yes), → TRANCN24. Else, → ND.10.0..
Response:

ND.9.2.
TRANCN24 Did you know this service existed?

0
No
1
Yes
8
Don't know
7
Refused to answer
Skip_TRANCN24 If TRANCN24 is 1 (yes), → TRANDN24. Else, → ND.10.0..
Response:

ND.9.3.
TRANDN24 Did you know how to get this service?

0
1
8
7

No
Yes
Don't know
Refused to answer

ND.8.2. – ND.9.3.

Page |117
Response:

ND.10.0.

SHLTA_5 During the past 12 months, did you get shelter or housing services where you got help with

temporary or long-term housing including section 8 vouchers?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_24_SHLTA_5 If ND.10.0. is 0 (no), 7 (refused to answer), or 8 (don’t know), → ND.10.1.. Else, → FOODAN5_24.
Response:

ND.10.1.
SHLTB_5 During the past 12 months, have you needed shelter or housing services?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_24_ SHLTB_5 If ND.10.1. is 1 (yes), → SHLTCN24. Else, → FOODAN5_24.
Response:

ND.10.2.
SHLTCN24 Did you know this service existed?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_SHLTCN24 If SHLTCN24 is 1 (yes), → SHLTDN24. Else, → FOODAN5_24.
Response:

ND.10.3.
SHLTDN24 Did you know how to get this service?

0
1
8
7
ND.11.0.

No
Yes
Don't Know
Refused to answer
Response:

FOODAN5_24 During the past 12 months, did you get food benefits from SNAP-The Supplemental Nutrition

Assistance Program or WIC-The Special Supplemental Nutrition Program for Women, Infants, and
Children?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_FOODAN5_24 If FOODAN5_24 is 0 (no), 7 (refused to answer), or 8 (don’t know), → FOODBN5_24. Else, → INTRO_24
_MLSF12_24.

ND.10.0. – ND.11.0.

Page |118
Response:

ND.11.1.

FOODBN5_24 During the past 12 months, have you needed food benefits from SNAP or WIC?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_FOODBN5_24 If FOODBN5_24 =1 (yes), → FOODCN24. Else → INTRO_24_MLSF12_24.
Response:

ND.11.2.
FOODCN24 Did you know this service existed?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_FOODCN24 If FOODCN24 =1 (yes), → FOODDN24. Else → INTRO_24_MLSF12_24.
Response:

ND.11.3.
FOODDN24 Did you know how to get this service?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

ND.12.0.

Text2Intro_24_MLSF12_24 Next, I’m going to ask about getting free or low-cost food. People may receive free or low-cost food
through food vouchers or gift cards, food pantries, food banks, soup kitchens, or free home delivered
meals.
MLSF12_24 During the past 12 months, did you get free or low-cost food?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_MLSF12_24 If MLSF12_24 is 0 (no), 7 (refused to answer) or 8 (don’t know), → MLSFOD_24. Else, → FATYPAN24.
Response:

ND.12.1.
MLSFOD_24 During the past 12 months, have you needed free or low-cost food?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_MLSFOD_24 If MLSFOD_24=1 (yes), → MEALCN24. Else, → FATYPAN24.
Response:

ND.12.2.
MEALCN24 Did you know this service existed?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_MEALCN24 If MEALCN24=1 (yes), → MEALDN24. Else, → FATYPAN24.
ND.11.1. – ND.12.2.

Page |119
Response:

ND.12.3.
MEALDN24 Did you know how to get this service?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

ND.12.4.

FATYPAN24 During the past 12 months, did you get any other type of food assistance?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_FATYPAN24 If FATYPAN24 is 1 (Yes) → FATYPAN24OS; Else, → ND.13.0..
Response:

ND.12.5.
FATYPAN24OS What type of food assistance did you get?

888 Don't Know
777 Refused to answer
Response:

ND.13.0.
GET_DOMS During the past 12 months, did you get domestic violence services?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_24_ GET_DOMS If ND.13.0. is 0 (no), 7 (refused to answer) or 8 (don’t know), → ND.13.1.. Else, → Intro_EMPLAN24.
Response:

ND.13.1.
NED_DOMS During the past 12 months, have you needed domestic violence services?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_24_NED_DOMS If ND.13.1. is 1 (yes), → DOMSCN24. Else, → Intro_EMPLAN24.
Response:

ND.13.2.
DOMSCN24 Did you know this service existed?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_DOMSCN24 If DOMSCN24 is 1 (yes), → DOMSDN24. Else, → Intro_EMPLAN24.

ND.12.3. – ND.13.2.

Page |120
Response:

ND.13.3.
DOMSDN24 Did you know how to get this service?

0
1
8
7

No
Yes
Don't Know
Refused to answer
Response:

ND.14.0.
Text2

Intro_EMPLAN24 Job assistance programs prepare you to get a job or help you consider other job opportunities.
EMPLAN24 During the past 12 months, did you get help from a job assistance program?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_EMPLAN24 If EMPLAN24 is 0 (no), 7 (refused to answer), or 8 (don’t know), → EMPLBN24. Else, → ND.14.0..
Response:

ND.14.1.

EMPLBN24 During the past 12 months, have you needed help from a job assistance program?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_EMPLBN24 If EMPLBN24 is 1 (yes)→ EMPLCN24. Else, → ND.14.0..
Response:

ND.14.2.
EMPLCN24 Did you know this service existed?

0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_EMPLCN24 If EMPLCN24 is 1 (yes)→ EMPLDN24. Else, → ND.14.0..
Response:

ND.14.3.
EMPLDN24 Did you know how to get this service?

0
1
8
7
ND.15.0.

No
Yes
Don't Know
Refused to answer
Response:

COND12_9 During the past 12 months, have you gotten any free condoms, not counting those given to you by a

friend, relative, or sex partner?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Skip_21_COND12_9 If ND.14.0. is 0 (no), 7 (refused to answer), or 8 (don't know), → ND.14.1.. Else, → INTRO_SSIA_N8.

ND.13.3. – ND.15.0.

Page |121
Response:

ND.15.1.
NEDCONDN21 During the past 12 months, have you needed free condoms?

0
1
8
7

No
Yes
Don't Know
Refused to answer

Topic: Other disability (NS)
Response:

NS.1.0.
Text2

Intro_SSIA_N8 "The next question is about Supplemental Security Income or SSI. SSI is a federal program that

provides money for food, clothing, and shelter for older persons or persons with disabilities."
SSIA_N8 During the past 12 months, did you get SSI?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Response:

NS.2.0.
Text2

Intro_SSDIA_N8 "Now I’m going to ask about Social Security Disability Insurance or SSDI. SSDI is a federal insurance

program that provides income to people unable to work because of a disability."
SSDIA_N8 During the past 12 months, did you get SSDI?
0
No
1
Yes
8
Don't Know
7
Refused to answer
N.0.a.
Calculation_ENNEEDN5 ENNEEDN5 = Current time

ND.15.1. – N.0.a.

Page |123

Module: Prevention activities (P)
Topic: Risk reduction (PR)
Response:

PR.1.0

Text2Intro_24_TALK_A_21 Now I'll ask you about preventing HIV and STDs.
TALK_A_21 During the past 12 months, have you talked to a doctor, nurse, or other healthcare worker about
how to prevent HIV or other STDs?
0
No
1
Yes
8
Don't know
7
Refused to answer
If POS1S_9 is Skipped, 8888 (don’t know), or 7777 (refused to answer), then display the text as
follows, “During the past 12 months, have you talked to a doctor, nurse, or other healthcare worker
about how to prevent HIV or other STDs?”
If POS1S_9 is less than 12 months from IDATE or POS1S_9M is missing and POS1S_9Y = 1 year from
IDATE then display the text as follows, "During the past 12 months, not including when you may
have been tested for HIV, have you talked to a doctor, nurse or other healthcare worker about how to
prevent HIV or other STDs?”
Response:

PR.2.0

TALK_B_21 During the past 12 months, have you talked to an outreach worker, counselor, or prevention

program worker about how to prevent HIV or other STDs?
0
No
1
Yes
8
Don't know
7
Refused to answer
If POS1S_9 is Skipped, 8888 (don’t know), or 7777 (refused to answer), then display the text as
follows, “During the past 12 months, have you talked to an outreach worker, counselor, or prevention
program worker about how to prevent HIV or other STDs?"
If POS1S_9 is less than 12 months from IDATE or POS1S_9M is missing and POS1S_9Y = 1 year from
IDATE then display the text as follows, "During the past 12 months, not including when you may have
been tested for HIV, have you talked to an outreach worker, counselor, or prevention program worker
about how to prevent HIV or other STDs?"

Topic: HIV treatment as prevention (PB)
Response:

PB.1.0.

TASP1N8 Have you heard that if you have an undetectable viral load, you will not pass on HIV to sexual

partners?
0
1
8
7

No
Yes
Don't know
Refused to answer

P.0.a.
Calculation_ENPREVN5 ENPREVN5 = Current time

PR.1.0 – P.0.a.

Page |125

Module: Interview completion (E)
Topic: End of interview (EE)
E.0.
Calculation_EN_INTN5 EN_INTN5 = Current time

EE.1.0.
Text2 Intro_RECCOMP_8 "Thank you again for taking part in this interview. Please remember that all the information you have
given me will be kept confidential. Now we are going to talk about services you may need or want."
RECCOMP Interview end date:
EE.2.0.
Calculation_LANGUAG If the English version of the questionnaire is used, then LANGUAG=EN. If the Spanish version of the

questionnaire is used, then LANGUAG=SP.
EE.3.0.
Calculation_VERSION Calculate questionnaire version number using variable name VERSION. This must be updated every

time a change is made in the application.

Topic: Referrals and follow-up (EO)
Response:

EO.1.0

Skip_RFLKPN8 If KE.1.0. is 0 (no), → EO.1.0. If KU.2.0. is > 12 months prior to IP.1.2., → EO.1.0. Else, → EO.2.0.

RFLKPN8 [DON'T READ ALOUD] Did you offer the respondent information about a provider or HIV agency they

can go to for HIV medical services or treatment? This includes offering them written or verbal
information such as a contact name, location, phone number, or hours of operation of a provider or
agency.
0
No
1
Yes, and respondent refused
2
Yes, and respondent accepted
Response:

EO.1.1

RFLKA1N8 [DON'T READ ALOUD] Did you offer to refer the respondent to a provider or HIV agency for

appropriate HIV medical services or treatment?
0
No
1
Yes, and respondent refused
2
Yes, and respondent accepted
Response:

EO.1.2

RFLKA2N8 [DON'T READ ALOUD] Did you offer to make a medical appointment for the respondent for HIV

medical services or treatment?
0
No
1
Yes, and respondent refused
2
Yes, and respondent accepted
Response:

EO.2.0

PREV_N8 [DON'T READ ALOUD] Did you offer the respondent HIV prevention materials such as palm cards,

pamphlets, or videos?
0
No
1
Yes, and respondent refused
2
Yes, and respondent accepted

E.0. – EO.2.0

Page |126
Response:

EO.3.0

Skip_SMOKCEN8 If US.1.1. is 1 (daily), 2 (weekly), 3 (monthly) or 4 (less than monthly), → EO.3.0. If US.2.1. is 1 (every

day), 2 (some days) or 3 (rarely), → EO.3.0. Else, → EO.4.0.
SMOKCEN8 Earlier, you said that a healthcare professional has not advised you to quit smoking in the past 12

months. Would you like any assistance, information, or additional advice to help you quit smoking?
0
No
1
Yes
8
Don't Know
7
Refused to answer
Tokens are used to alter how this question appears based on the respondent’s answer to CIG_DQ_8. If
CIG_DQ_8 is 0 (no), then question should read, “Earlier, you said that a healthcare professional has
not advised you to quit smoking in the past 12 months. Would you like any assistance, information, or
advice to help you quit smoking?” If CIG_DQ_8 is 1 (yes), then question should read, “Earlier, you said
that a healthcare professional advised you to quit smoking in the past 12 months. Would you like any
assistance, information, or additional advice to help you quit smoking?” If CIG_DQ_8 is 7 (don’t know)
or 8 (Refused), the question should read “Earlier, we asked you if a healthcare professional has
advised you to quit smoking in the past 12 months. Would you like any assistance, information, or
additional advice to help you quit smoking?”
Response:

EO.4.0

RFANS_8 [DON'T READ ALOUD] Which of the following additional resources were or will be offered to the

respondent? [SELECT ALL THAT APPLY.]
[Resources previously indicated as needed by the respondent are flagged with an asterisk (*)]
Response:

EO.4.0.
RFANS_8A HIV case management services

0
1

No
Yes
Response:

EO.4.0.
RFANS_8B Adherence counseling

0
1

No
Yes
Response:

EO.4.0.
RFANS_8C ADAP

0
1

No
Yes
Response:

EO.4.0.
RFANS_8D Patient navigation

0
1

No
Yes
Response:

EO.4.0.
RFANS_8E HIV peer group support

0
1

No
Yes

EO.3.0 – EO.4.0.

Page |127
Response:

EO.4.0.
RFANS_8F Dental care

0
1

No
Yes
Response:

EO.4.0.
RFANS_8G Drug or alcohol counseling or treatment

0
1

No
Yes
Response:

EO.4.0.
RFANS_8H Mental health services

0
1

No
Yes
Response:

EO.4.0.
RFANS_8I Transportation

0
1

No
Yes
Response:

EO.4.0.
RFANS_8J Shelter or housing services

0
1

No
Yes
Response:

EO.4.0.
RFANS_8K Food assistance

0
1

No
Yes
Response:

EO.4.0.
RFANS_8L Meal or food services

0
1

No
Yes
Response:

EO.4.0.
RFANS_8M Domestic violence services

0
1

No
Yes
Response:

EO.4.0.
RFANS_8R Job assistance services

0
1

No
Yes
Response:

EO.4.0.
RFANS_8N Tobacco cessation services

0
1

No
Yes

EO.4.0. – EO.4.0.

Page |128
Response:

EO.4.0.
RFANS_8P Condoms

0
1

No
Yes
Response:

EO.4.0.
RFANS_8Q No ancillary resources offered

0
No
1
Yes
If EO.4.0., EO.4.0., EO.4.0., EO.4.0., EO.4.0., EO.4.0., EO.4.0., EO.4.0., EO.4.0., EO.4.0., EO.4.0., EO.4.0.,
EO.4.0., RFANS_8R, EO.4.0., or EO.4.0. is selected and EO.4.0. is selected, then READ: You cannot
select an ancillary service and also select that none was offered. Correct the error. Program should not
move forward until error is corrected.

Topic: Data validity (EV)
Response:

EV.1.0.
Text2

Intro_N8_CONF Interviewer instructions [DON'T READ ALOUD]: Don’t pay the respondent if the respondent already

participated in an MMP interview during the [INSERT CYCLE YEAR] data collection cycle OR the
respondent is < 18 years old. Pay the respondent if the interview was partially or fully completed.
CONF [DON'T READ ALOUD] How confident are you of the validity of the respondent’s answers?
1
Confident
2
Some doubts
3
Not confident at all
Response:

EV.2.0.

ADDCOM1 [DON'T READ ALOUD] Record any additional comments, including disruptions that might have taken

place during the interview, reason the interview might have been stopped, or why the respondent’s
answers may not have been reliable.
666
Not Applicable

Topic: Local questions (EL)
EL.1.0.

Response:
LOCSURN6 Interviewer instructions: Does your project area ask local questions? If yes, press "Yes" to continue

to local questions. If not, press "No" to end.
0
No
1
Yes

EO.4.0. – EL.1.0.

AI1

2023
Su
1
8
15
22
29

Mo
2
9
16
23
30

January 23
Tu We Th
3 4 5
10 11 12
17 18 19
24 25 26
31

Fr
6
13
20
27

Sa
7
14
21
28

April 23
Su Mo Tu We Th Fr Sa
1
2 3 4 5 6 7 8
9 10 11 12 13 14 15
16 17 18 19 20 21 22
23 24 25 26 27 28 29
30

July 23
Su Mo Tu We Th Fr Sa
1
2 3 4 5 6 7 8
9 10 11 12 13 14 15
16 17 18 19 20 21 22
23 24 25 26 27 28 29
30 31

Su
1
8
15
22
29

Mo
2
9
16
23
30

October 23
Tu We Th
3 4 5
10 11 12
17 18 19
24 25 26
31

Fr
6
13
20
27

Sa
7
14
21
28

February 23
Su Mo Tu We Th
1 2
5 6 7 8 9
12 13 14 15 16
19 20 21 22 23
26 27 28

Fr
3
10
17
24

Sa
4
11
18
25

March 23
Su Mo Tu We Th
1 2
5 6 7 8 9
12 13 14 15 16
19 20 21 22 23
26 27 28 29 30

Fr
3
10
17
24
31

Sa
4
11
18
25

June 23
Tu We Th
1
6 7 8
13 14 15
20 21 22
27 28 29

Fr
2
9
16
23
30

Sa
3
10
17
24

May 23
Tu We Th
2 3 4
9 10 11
16 17 18
23 24 25
30 31

Fr
5
12
19
26

Sa
6
13
20
27

August 23
Su Mo Tu We Th
1 2 3
6 7 8 9 10
13 14 15 16 17
20 21 22 23 24
27 28 29 30 31

Fr
4
11
18
25

Sa
5
12
19
26

September 23
Su Mo Tu We Th Fr
1
3 4 5 6 7 8
10 11 12 13 14 15
17 18 19 20 21 22
24 25 26 27 28 29

Sa
2
9
16
23
30

Sa
4
11
18
25

December 23
Mo Tu We Th Fr
1
4 5 6 7 8
11 12 13 14 15
18 19 20 21 22
25 26 27 28 29

Sa
2
9
16
23
30

Su Mo
1
7 8
14 15
21 22
28 29

Su
5
12
19
26

November 23
Mo Tu We Th
1 2
6 7 8 9
13 14 15 16
20 21 22 23
27 28 29 30

Fr
3
10
17
24

Su Mo

4 5
11 12
18 19
25 26

Su
3
10
17
24
31

BI1

2024
January 24
Su Mo Tu We Th
7

4

Fr

Sa

February 24
Su Mo Tu We Th

Fr

Sa

5

6

1

2

3

8

9

10

1

2

3

8

9

10 11 12 13

4

5

6

7

March 24
Su Mo Tu We Th
3

4

5

6

7

Fr

Sa

1

2

8

9

14 15 16 17 18 19 20

11 12 13 14 15 16 17

10 11 12 13 14 15 16

21 22 23 24 25 26 27

18 19 20 21 22 23 24

17 18 19 20 21 22 23

28 29 30 31

25 26 27 28 29

24 25 26 27 28 29 30

31

April 24
Su Mo Tu We Th

Sa

5

6

1

2

3

8

9

10 11 12 13

Fr

Sa
4

June 24
Su Mo Tu We Th

Fr

Sa

1

2

3

8

9

10 11

2

3

14 15 16 17 18 19 20

12 13 14 15 16 17 18

9

10 11 12 13 14 15

21 22 23 24 25 26 27

19 20 21 22 23 24 25

16 17 18 19 20 21 22

28 29 30

26 27 28 29 30 31

23 24 25 26 27 28 29

7

4

Fr

May 24
Su Mo Tu We Th
5

6

7

1
4

5

6

7

8

30

July 24
Su Mo Tu We Th
7

4

Fr

Sa

August 24
Su Mo Tu We Th

5

6

1

2

3

1

2

3

8

9

10

8

9

10 11 12 13 14

1

2

3

8

9

10 11 12 13

4

5

6

7

Fr

Sa

September 24
Su Mo Tu We Th Fr

Sa
7

4

5

6

14 15 16 17 18 19 20

11 12 13 14 15 16 17

15 16 17 18 19 20 21

21 22 23 24 25 26 27

18 19 20 21 22 23 24

22 23 24 25 26 27 28

28 29 30 31

25 26 27 28 29 30 31

29 30

October 24
Su Mo Tu We Th

Fr

Sa

November 24
Su Mo Tu We Th Fr

Sa

December 24
Su Mo Tu We Th Fr

Sa

1

2

3

4

5

1

2

1

2

3

7

8

9

10 11 12

8

9

8

9

10 11 12 13 14

6

7

3

4

5

6

7

4

5

6

13 14 15 16 17 18 19

10 11 12 13 14 15 16

15 16 17 18 19 20 21

20 21 22 23 24 25 26

17 18 19 20 21 22 23

22 23 24 25 26 27 28

27 28 29 30 31

24 25 26 27 28 29 30

29 30 31

CI1

2025
January 25
Su Mo Tu We Th

Fr

Sa
4

February 25
Su Mo Tu We Th

Fr

Sa

March 25
Su Mo Tu We Th

Fr

1

2

3

8

9

10 11

2

3

8

2

3

12 13 14 15 16 17 18

9

10 11 12 13 14 15

9

10 11 12 13 14 15

19 20 21 22 23 24 25

16 17 18 19 20 21 22

16 17 18 19 20 21 22

26 27 28 29 30 31

23 24 25 26 27 28

23 24 25 26 27 28 29

5

6

7

1

Sa

4

5

6

7

1
4

5

6

7

8

30 31

April 25
Su Mo Tu We Th

Fr

1

2

3

4

8

9

10 11 12

6

7

Sa

May 25
Su Mo Tu We Th

Fr

5

1
8

4

5

6

7

Sa

June 25
Su Mo Tu We Th

Fr

Sa

2

3

1

2

3

6

7

9

10

8

9

10 11 12 13 14

4

5

13 14 15 16 17 18 19

11 12 13 14 15 16 17

15 16 17 18 19 20 21

20 21 22 23 24 25 26

18 19 20 21 22 23 24

22 23 24 25 26 27 28

27 28 29 30

25 26 27 28 29 30 31

29 30

July 25
Su Mo Tu We Th

Fr

Sa

August 25
Su Mo Tu We Th

September 25
Su Mo Tu We Th Fr

1

2

3

4

5

8

9

10 11 12

6

7

3

4

5

6

7

Fr

Sa

1

2

8

9

7

4

5

Sa

1

2

3

6

8

9

10 11 12 13

13 14 15 16 17 18 19

10 11 12 13 14 15 16

14 15 16 17 18 19 20

20 21 22 23 24 25 26

17 18 19 20 21 22 23

21 22 23 24 25 26 27

27 28 29 30 31

24 25 26 27 28 29 30

28 29 30

31

October 25
Su Mo Tu We Th

Fr

Sa
4

November 25
Su Mo Tu We Th Fr

Sa

December 25
Su Mo Tu We Th Fr

1

2

3

8

9

10 11

2

3

12 13 14 15 16 17 18

9

10 11 12 13 14 15

14 15 16 17 18 19 20

19 20 21 22 23 24 25

16 17 18 19 20 21 22

21 22 23 24 25 26 27

26 27 28 29 30 31

23 24 25 26 27 28 29

28 29 30 31

5

6

7

1

30

4

5

6

7

8

7

4

5

Sa

1

2

3

6

8

9

10 11 12 13

D

Response cards
Response Card A
Monthly Household Income

Yearly Household Income

a.

$0 to $916 per month

or

$0 to $10,999 per year

b.

$917 to $1,083 per month

or

$11,000 to $12,999 per year

$1,084 to $1,249 per month

or

$13,000 to $14,999 per year

d.

$1,250 to $1,416 per month

or

$15,000 to $16,999 per year

e.

$1,417 to $1,666 per month

or

$17,000 to $19,999 per year

f.

$1,667 to $2,083 per month

or

$20,000 to $24,999 per year

g.

$2,084 to $2,499 per month

or

$25,000 to $29,999 per year

h.

$2,500 to $3,333 per month

or

$30,000 to $39,999 per year

i.

$3,334 to $4,166 per month

or

$40,000 to $49,999 per year

j.

$4,167 to $6,249 per month

or

$50,000 to $74,999 per year

k.

$6,250 or more per month

or

$75,000 or more per year

c.

I

1

D |2

Response Card B
Extremely
Quite a bit
Somewhat
A little bit
Not at all
Response Card D
Never
Rarely
About half of the time
Most of the time
Always
Response Card E
Not at all
Several days
More than half the days
Nearly every day

D |3

Response Card F
Daily
Weekly
Monthly
Less than monthly
Never
Response Card G
Strongly disagree
Somewhat disagree
Neutral
Somewhat agree
Strongly agree
Alcohol Response Card