These questions are part of a data collection effort about how to prevent substance abuse and HIV infection. The questions are being asked of hundreds of other individuals throughout the United States. The data findings will be used to help prevention initiatives learn more about how to keep people from using drugs and getting infected with HIV.
Completing this questionnaire is voluntary. If you do not want to answer any of the questions, you do not have to. If you decide not to participate in this survey, it will have no effect on your participation in direct service programs. However, your answers are very important to us. Please answer the questions honestly-based on what you really do, think, and feel. Your answers will not be told to anyone in your family or community. Do not write your name anywhere on this questionnaire.
We would like you to work fairly quickly so that you can finish. Please work quietly by yourself. If you have any
questions or don't understand something, let the data collector know.
We think you will find the questionnaire to be interesting and that you will like filling it out. Thank you very much for being an important part of this data collection effort!
Date:
* must provide value
Today M-D-Y
Please create a code number using your initials, gender, last four digits of social security, 2 digit day of birth
Example: John Doe born on February 15 with last four Social security of 2222 would be JDM222215
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Section One: Facts About You
How would you describe yourself?
Male Female Transgender
Male to female Female to male
In what year were you born? (Ex. 1990)
Are you of Hispanic, Latino/a, or Spanish origin? (If yes, you may select one or more categories)
What is your race? (Select one or more)
Have you ever had sex with a man?
Yes
No
Have you ever had sex with a woman?
Yes
No
How would you describe yourself? (Sexual orientation)
Straight or heterosexual Bisexual Gay or lesbian Unsure
How well do you speak English?
Very well Well Not well Not at all
What is your primary spoken language?
English Spanish Asian (Chinese, Japanese, or other) American Indian (Apache, Blackfoot, Navajo, or other) Other
What is the highest level of education you have finished, whether or not you received a degree? (Pick the highest grade you have completed.)
Elementary school Middle school High school Community college or technical or trade school Four-year college Beyond four-year college
Are you currently attending college?
No Yes- I live on campus Yes- I live off campus
Which College/University do you attend?
American Baptist College Aquinas College Art Institute of Tennessee Belmont University Fisk University Lipscomb University Meharry Medical College Nashville State Community College Tennessee State University Trevecca-Nazarene University Vanderbilt University Watkins College of Art, Design, and Film Other
Which of the following best describes you? (Pick the one that fits best)
Employed full-time (35+ hours per week) Employed part-time Unemployed (full-time student) Unemployed (other reason)
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone-such as visiting a doctor's office or shopping?
Yes
No
If you have ever been in juvenile/adult detention, jail, or prison for more than 3 days, how long has it been since you last got out?
Never in juvenile/adult detention, jail, or prison for more than 3 days Less than two years Two years or more
Have you ever served in the Armed Forces, in the Reserves, or the National Guard [select all that apply]?
Are you currently on active duty in the Armed Forces, in the Reserves, or the National Guard?
Yes, in the Armed Forces Yes, in the Reserves Yes, in the National Guard No, separated or retired from Armed Forces, Reserves, or National Guard
Have you ever been deployed to a combat zone [select all that apply]?
Is anyone in your family or someone close to you on active duty in the Armed Forces, in the Reserves or the National Guard, or separated or retired from the Armed Forces, the Reserves, or the National Guard?
No Yes- 1 person Yes- 2 people Yes- 3 people Yes- 4 people Yes- 5 people Yes- 6 or more people
Mother/Father Brother/Sister Spouse/Partner Child Other
Mother/Father Brother/Sister Spouse/Partner Child Other
Mother/Father Brother/Sister Spouse/Partner Child Other
Mother/Father Brother/Sister Spouse/Partner Child Other
Mother/Father Brother/Sister Spouse/Partner Child Other
Mother/Father Brother/Sister Spouse/Partner Child Other
Everyday Discrimination
In your day-to-day life how often have any of the following things happened to you?
You are treated with less courtesy or respect than other people.
Almost everyday At least once a week A few times a month A few times a year Less than once a year Never
You receive poorer service than other people at restaurants or stores.
Almost everyday At least once a week A few times a month A few times a year Less than once a year Never
People act as if they think you are not smart.
Almost everyday At least once a week A few times a month A few times a year Less than once a year Never
People act as if they are afraid of you.
Almost everyday At least once a week A few times a month A few times a year Less than once a year Never
You are threatened or harassed.
Almost everyday At least once a week A few times a month A few times a year Less than once a year Never
What do you think is the main reason for these experiences? You may select more than one reason.
The following questions are about what you believe people think about people living with HIV. Please check the response that indicates how much you agree with each statement.
People are afraid of those with HIV
Strongly Disagree Disagree Agree Strongly Agree
People do not want to talk to others with HIV
Strongly Disagree Disagree Agree Strongly Agree
People prefer not to have those with HIV living in their community
Strongly Disagree Disagree Agree Strongly Agree
People think that people with HIV are unclean
Strongly Disagree Disagree Agree Strongly Agree
People try not to touch others with HIV
Strongly Disagree Disagree Agree Strongly Agree
People feel uncomfortable being near those with HIV
Strongly Disagree Disagree Agree Strongly Agree
People do not want those with HIV playing with their children
Strongly Disagree Disagree Agree Strongly Agree
If a person has HIV, community members will behave differently towards that person for the rest of his/her life
Strongly Disagree Disagree Agree Strongly Agree
People who have HIV lose friends when they share with them they have HIV
Strongly Disagree Disagree Agree Strongly Agree
People who have HIV feel alone
Strongly Disagree Disagree Agree Strongly Agree
People who have HIV feel hurt because of how others react to knowing they have HIV
Strongly Disagree Disagree Agree Strongly Agree
People who have HIV are afraid that other people in the community will talk about them having HIV
Strongly Disagree Disagree Agree Strongly Agree
People who have HIV will choose carefully who they tell about having HIV
Strongly Disagree Disagree Agree Strongly Agree
People who have HIV worry that others will reveal their secret
Strongly Disagree Disagree Agree Strongly Agree
People who have HIV try very hard to keep their HIV a secret
Strongly Disagree Disagree Agree Strongly Agree
The following questions ask you about your feelings and thoughts during the last month. In each case, you will be asked to indicate how often you felt or thought a certain way.
In the last month, how often have you been upset because of something that happened unexpectedly?
Very Often Fairly Often Sometimes Almost Never Never
In the last month, how often have you felt that you were unable to control the important things in your life?
Very Often Fairly Often Sometimes Almost Never Never
In the last month, how often have you felt nervous and "stressed"?
Very Often Fairly Often Sometimes Almost Never Never
In the last month, how often have you felt confident about your ability to handle your personal problems?
Very Often Fairly Often Sometimes Almost Never Never
In the last month, how often have you felt that things were going your way?
Very Often Fairly Often Sometimes Almost Never Never
In the last month, how often have you found that you could not cope with all the things that you had to do?
Very Often Fairly Often Sometimes Almost Never Never
In the last month, how often have you been able to control irritations in your life?
Very Often Fairly Often Sometimes Almost Never Never
In the last month, how often have you felt that you were on top of things?
Very Often Fairly Often Sometimes Almost Never Never
In the last month, how often have you been angered because of things that were outside of your control?
Very Often Fairly Often Sometimes Almost Never Never
Section Two: Attitudes & Knowledge
Next, we'd like to ask you about your knowledge, attitudes, and/or feelings about sexual behavior, substance use, and HIV. Again, your answers are private and will not be used to identify you.
Have you heard of PrEP (Pre-Exposure Prophylaxis)?
Yes
No
Would you be interested in using PreP?
Yes
No
What makes you interested (check all that apply)?
Why not (check all that apply)?
Who should be using PrEP (check all that apply)?
How much do people risk harming themselves physically or in other ways when they smoke one or more packs of cigarettes per day?
No risk Slight risk Moderate risk Great risk Don't know or can't say
How much do people risk harming themselves physically or in other ways when they smoke marijuana once or twice a week?
No risk Slight risk Moderate risk Great risk Don't know or can't say
How much do people risk harming themselves physically or in other ways when they have five or more drinks of an alcoholic beverage once or twice a week?
No risk Slight risk Moderate risk Great risk Don't know or can't say
How many of your friends and acquaintances often have 5 or more drinks in one sitting?
None of them A few of them Some of them Most of them All of them
How would you feel about your close friends frequently having 5 or more drinks in one sitting?
I would strongly disapprove I would disapprove I would neither approve nor disapprove I would approve I would strongly approve
How would you feel about your close friends regularly engaging in unprotected sexual activity?
I would strongly disapprove I would disapprove I would neither approve nor disapprove I would approve I would strongly approve
The next questions are about your beliefs and attitudes toward SEX.
Some of the questions ask about having sex. By sex or sexual activity, we mean a situation where two partners get sexually excited or aroused (turned on) by touching each other's genitals (penis or vagina) or anus (butt) with their own genitals, hands, or mouth.
When a male inserts his penis into his female partner's vagina, the partners are considered to be having vaginal sex.
When one partner's mouth is in contact with the other partner's genitals (penis or vagina) or anus during sex, the partners are considered to be having oral sex.
When a male's penis is inserted into his male or female partner's anus, the partners are considered to be having anal sex.
Some questions ask about sexual partners. A sexual partner is someone with whom you have sex, that is, engage in sexual activity.
Some questions refer to protected sex and unprotected sex. Protected sex is when a latex or polyurethane condom (rubber) is used to cover the penis; a female condom is used to cover the vagina; or a dental dam is used to cover the anus. By unprotected sex, we mean vaginal, oral, or anal sex without a barrier such as a condom or dental dam.
How much do you think people risk harming themselves physically...
If they have sex (oral, vaginal, or anal) without a condom or dental dam?
No risk Slight risk Moderate risk Great risk
If they have sex while high on drugs or under the influence of alcohol?
No risk Slight risk Moderate risk Great risk
If they share unsanitized needles or works when using drugs?
No risk Slight risk Moderate risk Great risk
Now think about your relationship with your PRIMARY (MAIN) partner. How confident are you that you could...
Refuse to have sex with your partner because you weren't in the mood?
Not at all A little Somewhat Very much
Ask your partner to wait while you got a condom or dental dam?
Not at all A little Somewhat Very much
Tell your partner how to treat you sexually?
Not at all A little Somewhat Very much
Refuse to engage in sexual practices you didn't like?
Not at all A little Somewhat Very much
Ask your partner to use a condom or dental dam?
Not at all A little Somewhat Very much
Refuse to have sex because your partner did not want to use a condom or dental dam?
Not at all A little Somewhat Very much
HIV/AIDS - What You Know
Please indicate whether you think each of the following five statements about HIV/AIDS is true or false or if you don't know.
Only people who look sick can spread HIV/AIDS?
True False Don't know
Only people who have sexual intercourse with gay (homosexual) people get HIV/AIDS.
True False Don't know
Birth control pills protect women from getting HIV/AIDS.
True False Don't know
There are drugs available to treat HIV that can lengthen the life of a person infected with the virus.
True False Don't know
There is no cure for AIDS.
True False Don't know
Would you know where to go near where you live to see a health care professional regarding HIV/AIDS or other sexually transmitted health issues?
Yes
No
Would you know where to go near where you live to see a health care professional regarding a drug or alcohol problem?
Yes
No
When you need medical help, generally how difficult is it for you to get to a service provider? Would you say it is:
Not at all difficult Not too difficult Somewhat difficult Very difficult
In your day-to-day life, do you ever feel that you are treated with less respect or receive poorer services than other people?
Yes
No
What do you think is the main reason for these experiences? (Check all that apply to you. If none of the answers apply, check "None of the above.")
Have you ever been informed of your HIV status (that is, whether or not you are HIV-positive) based on the result of an HIV test?
Yes
No
Now we would like you to think about all the people you know. Are there certain people you could go to when you want to talk about personal matters that you wouldn't tell just anyone?
Yes
No
In general, how important are religious or spiritual beliefs in your day-to-day life?
Not at all important Not too important Fairly important Very important
The last question asks about your experience with this survey.
How truthful were you when answering the questions?
Very truthful Somewhat truthful Somewhat untruthful Very untruthful