Attachment 2_Revised Deferral Study Q

DEFERRAL QUESTIONNAIRE (English)

SECTION A - STUDY DATA

This section is to be completed by research assistant or other research staff.

A1. STUDY ID

__ __ __ __ __

A2. Blood collection site (Choose one)

1 Fundação Pró-Sangue - São Paulo

2 HEMOMINAS - Minas Gerais

3 HEMOPE - Pernambuco

4 HEMORIO-Rio de Janeiro

UID = Concatenated(A2, A1)

A3. Month of interview (Choose one)

01 January

02 February

03 March

04 April

05 May

06 June

07 July

08 August

09 September

10 October

11 November

12 December

A4. Year of interview (please enter four numbers)

__ __ __ __ yyyy

YEAR2 = A4 - 1

A5. Research Assistant Initials: __ __ __ __ __

A6. Study subject is able to read

1 Yes

0 No

A7. What level of education do you have? (Choose one)

00 not used in US

01 Never been to school

02 Elementary school

03 High school

04 College or Technical school

05 Graduate school or Professional degree

06 not used in US

07 not used in US

08 not used in US

97 Don't Know

98 Refuse to Answer

A8. Even if you are currently not working, what is your occupation?

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

A9. Type of interview (Choose one)

1 CASI

2 ACASI

3 Paper

READ: If study subject is not already sitting at the computer, at this time please make sure the study subject is sitting at the computer and has put the headphones on.

SECTION B - DEMOGRAPHIC DATA

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including time for reviewing instructions, 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: OMB# (0925-XXXX).

READ: This study has been approved by Ethical Committees in Brazil and the USA.

READ: The following questions are about your general characteristics. Please, respond as truthfully as you can, and keep in mind that your answers are anonymous and will be reported together with all other participants who complete this questionnaire.

B1. What is your gender?

1 Male

2 Female

B2. What is your birth year?

__ __ __ __

9997 Don't Know

9998 Refuse to Answer

B3. What is your birth month? (Choose one)

__ __ January

__ __ February

__ __ March

__ __ April

__ __ May

__ __ June

__ __ July

__ __ August

__ __ September

__ __ October

__ __ November

__ __ December

__ __ Don't Know

__ __ Refuse to Answer

B4. What is your birthday?

__ __

97 Don't Know

98 Refuse to Answer

B5. What is your country of birth? (Choose one)

1 Brazil

2 Other

7 Don't Know

8 Refuse to Answer

If B5 is not equal to 2, then skip to instruction before B6.

B5a. Please specify your country of birth

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

READ: From now on, you will be left alone. It means that you will have total privacy to complete the interview. Please, if you have any questions call the research assistant for help.

B6. What is your ethnicity? (Mark One or More)

1 Caucasian

2 Black

3 Asian or yellow

4 Mulatto

5 Indian

7 Don't Know

8 Refuse to Answer

B7. What is your current marital status? (Choose one)

1 Single, never married

2 Living together, but not legally married

3 Married

4 Separated/ divorced

5 Widowed

7 Don't Know

8 Refuse to Answer

If B7 is not equal to 2 and B7 is not equal to 3, then skip to B8.

B7a. If you are married or living with someone, is your spouse/cohabiting partner (Choose one)

1 Female

2 Male

7 Don't Know

8 Refuse to Answer

B8. What is your current employment status? (Choose one)

0 Unemployed

1 Employed

2 Self-employed

3 Student

4 Retired

7 Don't Know

8 Refuse to Answer

B9. What is combined the monthly income for all members living in your household? (Choose one)

0 Less than R$ 500 (US$ 250)

1 Between R$ 501 and R$ 1,000 (US$ 251-500)

2 Between R$ 1,001 and R$ 3,000 (US$ 501- 1500)

3 Between R$ 3,001 and R$ 6,000 (US$ 1501- 3.000)

4 More than R$ 6,001 (US$ 3001)

7 Don't Know

8 Refuse to Answer

SECTION C - BLOOD DONATION

READ: The following questions are about blood donation. Please, respond as truthfully as you can. Your answers are anonymous and will be reported together with all other participants who complete this questionnaire.

C1. Did you come to donate blood today to help a friend or relative undergoing treatment at the hospital?

1 Yes

0 No

7 Don't Know

C2. How many times have you donated blood before at this or another blood center? (Choose one)

0 Never donate before

1 1 to 3 times

2 4 or more times

7 Don't Know

8 Refuse to Answer

C3. Please, indicate which of the following statements describe why you came to the blood center to donate blood. (Check all that apply)

__ To help a friend or relative undergoing treatment at the hospital

__ I received a letter from the blood bank, or a phone call from the blood bank

__ I wanted to get the day off work

__ In response to a TV or Radio announcement

__ My friend came and I decided to come too

__ My blood type is in high demand

__ I was passing by and decided to come in

__ None of them

__ Don't Know

__ Refuse to Answer

C4. Did any of the following factors have influence your decision to try to donate blood? (Check all that apply)

__ To help someone in need of blood

__ I think it is good to give blood to help someone

__ I believe I am doing something important

__ I think blood donation is important for society

__ I may need blood myself someday

__ I want to get tested

__ I like to know about my health and giving blood is one way to find out

__ Blood center testing is more accurate than at other test sites

__ Blood center testing is confidential

__ Blood center testing is free

__ I was curious

__ None of them

__ Don't Know

__ Refuse to Answer

SECTION D - DEFERRAL

READ: Now we want to ask about the deferral that you received today and any other deferrals you might have had as a blood donor. Please answer these questions to the best of your knowledge.

D1. Do you know the reason for today's deferral?

1 Yes

0 No

7 Don't Know

8 Refuse to Answer

D1a. What was the reason? Please specify

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

D2. Do you understand the reason for today's deferral?

1 Yes

0 No

7 Don't Know

8 Refuse to Answer

D3. What feelings do you have about today's deferral? (Check all that apply)

__ Disappointed

__ Relieved

__ Angry

__ Content

__ Unpleasant

__ Surprised

__ Nervous

__ Fear

__ Unfair

__ Other

__ Don't Know

__ Refuse to Answer

If D3 is not equal to 10, then skip to D4.

D3a. Please, specify other feelings

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

D4. Before today, have you ever been deferred from donating blood?

1 Yes

0 No Skip to instruction before E1

7 Don't Know

8 Refuse to Answer

D4a. In total, including today, how many times have you been deferred? (Choose one)

0 1 time

1 2 or more times

7 Don't Know

8 Refuse to Answer

SECTION E - BLOOD TESTING AND HIV KNOWLEDGE

READ: The following questions are about blood testing and HIV knowledge. We are asking you to respond as truthfully as you can. Keep in mind that your answers are anonymous and will be reported together with all other people who complete this questionnaire.

E1. Do you believe that the blood center uses better HIV tests than are available at other places?

1 Yes

0 No

7 Don't Know

8 Refuse to Answer

E2. Did you try to donate blood today because you wanted to be tested for HIV?

1 Yes

0 No

7 Don't Know

8 Refuse to Answer

If E2 is not equal to 1, then skip to E4.

E3. Please check all the boxes for the factors that contributed to your decision to come to the blood center to be tested for HIV. When you have selected all of your answers, please touch the "Next Question" box. (Check all that apply)

__ Only place I know of offering tests

__ Testing is free

__ Testing is confidential

__ Testing is more accurate than at other sites

__ Testing is more convenient than at other test sites

__ Other reason

__ Don't Know

__ Refuse to Answer

If E3 is not equal to 6, then skip to E4.

E3a. Please specify other reason

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

E4. Other than blood donation, have you ever been tested for HIV?

1 Yes

0 No Skip to E5

7 Don't Know

8 Refuse to Answer

E4a. What was the reason for the HIV test? (Choose one)

1 Pregnancy care

2 Health insurance

3 Physician's order, routine medical care, hospitalization or surgery

4 I wanted to know my HIV status

5 Other

7 Don't Know

8 Refuse to Answer

If E4a is not equal to 5, then skip to E5.

E4b. Please specify the other reason for the HIV test.

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

E5. Did you try to donate blood today because you wanted to be tested for hepatitis?

1 Yes

0 No

7 Don't Know

8 Refuse to Answer

If E5 is not equal to 1, then skip to E6.

E5a. Please check all the boxes for the factors that contributed to your decision to come to the blood center to be tested for Hepatitis When you have selected all of your answers, please touch the "Next Question" box. (Check all that apply)

__ Only place I know of offering tests

__ Testing is free

__ Testing is confidential

__ Testing is more accurate than at other sites

__ Testing is more convenient than at other test sites

__ Other reason

__ Don't Know

__ Refuse to Answer

If E5a is not equal to 6, then skip to E6.

E5b. Please specify the other reason

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

E6. Did you come to the blood center to be tested for some other reason?

1 Yes

0 No Skip to E7

7 Don't Know

8 Refuse to Answer

E6a. Please specify the other reason

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

E7. Did a health worker, such as a doctor, nurse, or someone from a health department, suggest that you go to the blood center for a blood test for HIV, hepatitis, or for some other reason?

1 Yes

0 No Skip to instruction before E8

7 Don't Know

8 Refuse to Answer

E7a. Who suggested that you come to the blood center to get tested? (Choose one)

0 Doctor

1 Nurse

2 Someone from the health department

3 Other

7 Don't Know

8 Refuse to Answer

READ: The following questions are about your opinion of blood testing and HIV.

E8. Do you think it is OK to donate blood in order to be tested for the AIDS virus?

1 Yes

0 No

7 Don't Know

8 Refuse to Answer

E9. Do you think it is OK to donate blood if you have engaged in risk behaviors for HIV or AIDS because the blood center tests all blood and throws away any infected blood ? (Choose one)

0 True

1 False

7 Don't Know

8 Refuse to Answer

E10. Do you think it is OK to donate blood even if you have engaged in risk behaviors for HIV or AIDS as long as you have a negative HIV test? (Choose one)

0 True

1 False

7 Don't Know

8 Refuse to Answer

E11. Do you think the blood test for HIV identifies everyone who is infected with the AIDS virus? (Choose one)

0 True

1 False

7 Don't Know

8 Refuse to Answer

SECTION G- GENERAL RISK FACTORS

READ: In the next section you will be asked some questions about exposures, medical procedures, or accidents. Some people have these factors while other people do not. Your answers will help to improve the blood safety. Please respond as truthfully as you can. Keep in mind that your answers are anonymous and will be reported together with other participants who complete this questionnaire.

G1. In total, how many tattoos do you have on your body? (Choose one)

0 0 ( No tattoos) Skip to G3

1 1

2 2

3 3 or more

7 Don't Know

8 Refuse to Answer

G2. In the last 12 months, have you had a new tattoo or had one re-applied?

1 Yes

0 No

7 Don't Know

8 Refuse to Answer

9 Not Applicable

G3. In total, how many ear and or body piercings do you have? (Choose one)

0 0 (No piercings) Skip to G5

1 1

2 2

3 3 or more

7 Don't Know

8 Refuse to Answer

G4. In the last 12 months, have you had any new ear or body piercings?

1 Yes

0 No

7 Don't Know

8 Refuse to Answer

9 Not Applicable

G5. Have you ever had a manicure or pedicure at a beauty salon or had a shave at a barbershop?

1 Yes

0 No Skip to G7

7 Don't Know

8 Refuse to Answer

9 Not Applicable Skip to G7

G6. In the past 12 months, have you had a manicure or pedicure at a beauty salon or had a shave at a barbershop?

1 Yes

0 No

7 Don't Know

8 Refuse to Answer

G7. Have you ever had any minor or major medical surgery, tooth extraction, or other dental procedures?

1 Yes

0 No Skip to G9

7 Don't Know

8 Refuse to Answer

G8. In the past 12 months, have you had any minor or major medical surgery, tooth extraction, or other dental procedures?

1 Yes

0 No

7 Don't Know

8 Refuse to Answer

G9. Have you ever had an endoscopy (a medical test where a flexible tube is used to look inside of your throat and digestive system) or colonoscopy (a medical test where a flexible tube is used to look inside your colon/large intestine)?

1 Yes

0 No Skip to G11

7 Don't Know

8 Refuse to Answer

G10. In the past 12 months, have you had endoscopy or colonoscopy?

1 Yes

0 No

7 Don't Know

8 Refuse to Answer

G11. In your professional work have you ever gotten someone else's blood, body fluids or excrement splashed into your eyes, mouth or in an open skin lesion?

1 Yes

0 No

7 Don't Know

8 Refuse to Answer

G12. In your professional work have you ever had a needle stick injury (accidentally been stuck by a needle or other sharp instrument used for providing medical care to someone else)?

1 Yes

0 No

7 Don't Know

8 Refuse to Answer

G13. Have you ever received a blood transfusion?

1 Yes

0 No Skip to instruction before G15

7 Don't Know

8 Refuse to Answer

G14. How many different times have you been transfused? (Choose one)

0 1 to 2 times

1 3 to 5 times

2 6 or more times

7 Don't Know

8 Refuse to Answer

READ: In the next section you will be asked some questions about sexual experiences and other behaviors. Some people have these experiences while others do not. Please respond as truthfully as you can. Keep in mind that your answers are anonymous and will be reported together with other participants who complete this questionnaire.

G15. To the best of your knowledge, have you had sex or intercourse with anyone who was an intravenous drug user?

1 Yes

0 No

7 Don't Know

8 Refuse to Answer

G16. To the best of your knowledge, have you had sex or intercourse with any male who has also had sex with another male?

1 Yes

0 No

7 Don't Know

8 Refuse to Answer

G17. To the best of your knowledge, have you had sex or intercourse with anyone who tested positive for hepatitis?

1 Yes

0 No

7 Don't Know

8 Refuse to Answer

G18. To the best of your knowledge, have you had sex or intercourse with anyone who tested positive for HIV?

1 Yes

0 No

7 Don't Know

8 Refuse to Answer

G19. To the best of your knowledge, have you had sex or intercourse with anyone who tested positive for Human T-lymphotropic virus (HTLV)?

1 Yes

0 No

7 Don't Know

8 Refuse to Answer

G20. To the best of your knowledge, have you had sex or intercourse with anyone who received a blood transfusion?

1 Yes

0 No

7 Don't Know

8 Refuse to Answer

G21. In the past 12 months, how many male sexual partners have you had? Please include both ongoing partners and one-time encounters. (Choose one)

__ Zero

__ 1 to 3

__ 3 to 5

__ more than 5

__ Don't Know

__ Refuse to Answer

If G21 is not equal to 0, then skip to G23.

G22. With regard to your sexual partners and one-time encounters in the above question, how often did you use condoms when you had sex? (Choose one)

0 Never

1 Sometimes

2 Always

7 Don't Know

8 Refuse to Answer

G23. In the past 12 months, how many female sexual partners have you had? Please include both ongoing partners and one-time encounters. (Choose one)

0 Zero

1 1 to 3

2 3 to 5

3 More than 5

7 Don't Know

8 Refuse to Answer

9 Not Applicable

If G23 is not equal to 0, then skip to G25.

G24. With regard to your sexual partners and one-time encounters in the above question, how often did you use condoms when you had sex? (Choose one)

0 Never

1 Sometimes

2 Always

7 Don't Know

8 Refuse to Answer

G25. Have you ever exchanged (given or received) money or drugs for sex?

1 Yes

0 No Skip to G27

7 Don't Know

8 Refuse to Answer

G26. In the last 12 months have you exchanged money or drugs for sex?

1 Yes

0 No

7 Don't Know

8 Refuse to Answer

G27. Have you ever injected illegal drugs, anabolic steroids or vitamins not prescribed by a doctor?

1 Yes

0 No Skip to G29

7 Don't Know

8 Refuse to Answer

G28. Have you ever shared needles or syringes with another person?

1 Yes

0 No

7 Don't Know

8 Refuse to Answer

G29. To the best of your knowledge, are any members of your family infected with HIV?

1 Yes

0 No Skip to G31

7 Don't Know

8 Refuse to Answer

G30. Can you tell us which family member is infected with HIV? (Check all that apply)

__ Mother

__ Father

__ Sister or brother

__ Other relative

__ Don't Know

__ Refuse to Answer

G31. To the best of your knowledge, are any members of your family infected with Hepatitis B or C?

1 Yes

0 No Skip to G33

7 Don't Know

8 Refuse to Answer

G32. Can you tell us which family member is infected with Hepatitis B or C? (Check all that apply)

__ Mother

__ Father

__ Sister or brother

__ Other relative

__ Don't Know

__ Refuse to Answer

G33. To the best of your knowledge, are any members of your family infected with HTLV?

1 Yes

0 No Skip to G35

7 Don't Know

8 Refuse to Answer

G34. Can you tell us which family member is infected with HTLV? (Check all that apply)

__ Mother

__ Father

__ Sister or brother

__ Other relative

__ Don't Know

__ Refuse to Answer

G35. What is your mother's ethnic background? (Choose one)

0 Caucasian

1 Black

2 Asian

3 Mulato

4 Indian

7 Don't Know

8 Refuse to Answer

If G35 is not equal to 2, then skip to end of questionnaire.

G36. If Asian, is your mother of Japanese descent?

1 Yes

0 No

7 Don't Know

8 Refuse to Answer

READ: You have finished the questionnaire. From now on, DO NOT touch the screen. Please, talk to the research assistant, the person who assisted you at the beginning of this questionnaire. This assistant will close the screen and acknowledge you for your participating in this study.

READ: Thank you for taking the time to complete this questionnaire. Please let your host know that you have finished the interview. If you have any questions or concerns, please talk to the research assistant or nurse. You can also contact the medical director at our blood bank.

ETIME = ENDTIME - CURTIME

Version 1 (DE14712EN) Page 3 01/07/10