Form Adult Questionnair Adult Questionnair Adult Questionnaire
Minority Substance Abuse/HIV Prevention Initiative
HIV Adult Questionnaire_120321
Adult
OMB: 0930-0298
Form Approved
OMB No.: 0930-0298
Expiration Date: XX/XX/XXXX
National Minority SA/HIV Prevention Initiative
Adult Questionnaire
TO BE COMPLETED BY THE LOCAL GRANT SITE DATA COLLECTOR
Last Name___________________, First Name___________________, M.I.______
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Participant ID #: _____________________ |
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RESPONDENT OR PARTICIPANT: Before answering any of the questions, please make sure your name is correct. If incorrect, make the change in the box above. Do not write your name on any other page in this questionnaire. Thank you.
National Minority SA/HIV Prevention Initiative
Adult Questionnaire
Funding
for data collection supported by the
Center for Substance Abuse
Prevention (CSAP)
Substance Abuse and Mental Health Services
Administration (SAMHSA)
U.S. Department of Health and Human
Services (HHS)
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!
Public Burden Statement: 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. The OMB control number for this project is 0930-0298. Public reporting burden for this collection of information is estimated to average 0.4 hours per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857. |
INSTRUCTIONS
1. Answer each question by marking one of the answer circles. Some questions allow you to mark more than one answer. If you don’t find an answer that fits exactly, choose the one that comes closest.
2. Mark your answers carefully so we can tell which answer circle you chose. Do not mark between the circles.
3. It is very important that you answer each question truthfully. Your responses will not be helpful unless you tell the truth. ___________________________________________________________________________________
MARKING YOUR ANSWERS
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Record Management Section: To be Completed by Designated Staff
Grant ID
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Study Design Group (Select one)
Intervention Comparison
Participant ID
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Date of Survey Administration
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Interview Type (Select one)
Baseline Exit Follow-up
Intervention Duration (Select one)
Single Session Intervention
Multiple Session Brief Intervention (less than 30 day duration)
Multiple Session Long Intervention (30 days or longer duration)
Intervention Name(s) (If the participant is receiving services for more than one intervention, please list each intervention below)
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Section
One: Facts About You
First, we’d like to ask some basic questions about you. Your answers will not be used to identify you in any way. Instead, your answers will help us understand how different groups (like men or women, or people of similar ages) feel about substance abuse and HIV prevention.
1. How would you describe yourself? (Gender)
Male
Female
Transgender
Male to female
Female to male
2. In what year were you born? (Enter all four digits of the year in the boxes below, and fill in corresponding circles)
-
1
2
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
3. In what month were you born?
January May September
February June October
March July November
April August December
4. Are you Hispanic or Latino?
Yes
No
5. What is your race? (Select one or more)
White
Black or African American
American Indian
Native Hawaiian or Other Pacific Islander
Asian
Alaska Native
Other
6. How would you describe yourself?
(Sexual orientation)
Straight or heterosexual
Bisexual
Gay or lesbian
Unsure
7. What is your primary spoken language?
English
Spanish
Asian (Chinese, Japanese, or other)
American Indian (Apache, Blackfoot, Navajo, or other)
Other
8. How long have you lived in the United States?
Less than a year
1 to 2 years
3 to 4 years
5 or more years
All my life
9. What is the highest level of education you have finished, whether or not you received a degree? (Mark the highest grade you have completed.)
1st grade College freshman
2nd grade College sophomore
3rd grade College junior
4th grade College completion
5th grade Some graduate school, but
6th grade no degree received
7th grade Master’s degree
8th grade Some professional school,
9th grade (such as medical or law
10th grade school) but no degree
11th grade received or doctoral
12th grade program
Doctorate or professional degree
10. If less than 12 years of education, do you have a GED (General Equivalency Diploma)?
Yes
No
11. Have you completed a technical or trade school program (such as beautician, cosmetology, business, appliance repair, computer etc.)?
Yes
No
12. Which of the following best describes you? (Mark the one that fits best)
Employed full time (35+ hours per week)
Employed part time
Unemployed (looking for work)
Unemployed (disabled)
Unemployed (volunteer work)
Unemployed (retired)
Unemployed (full-time student)
Unemployed (full-time homemaker)
Unemployed (other reason)
13. During the past 12 months, have you driven a vehicle while you were under the influence of alcohol?
Yes
No
Don’t know or can’t say
Have you ever been in juvenile/adult detention, jail, or prison for more than 3 days?
Yes
No
15. If YES to question 14, how long has it been since you last got out of juvenile/adult detention, jail, or prison?
Never in juvenile/adult detention, jail, or prison for more than 3 days
Fewer than 30 days
Between 30 days and 1 year
Between 1 and 2 years
Between 2 and 3 years
Between 3 and 4 years
Between 4 and 5 years
More than 5 years
16. Have you ever served in the Armed Forces, in the Reserves, or the National Guard [select all that apply]?
No, (Skip to #17)
Yes, in the Armed Forces
Yes, in the Reserves
Yes, in the National Guard
16a. Are you currently on active duty in the Armed Forces, in the Reserves, or the National Guard [select all that apply]?
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
16b. Have you even been deployed to a combat zone [select all that apply]?
Never deployed
Iraq or Afghanistan (e.g., Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn)
Persian Gulf (Operation Desert Shield or Desert Storm)
Vietnam/Southeast Asia
Korea
WWII
Deployed to a combat zone not listed above (e.g., Somalia, Bosnia, Kosovo)
17. 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 Armed Forces, Reserves, or the National Guard?
No, (Skip to #19)
Yes, 1 person
Yes, 2 people
Yes, 3 people
Yes, 4 people
Yes, 5 people
Yes, 6 or more people
18. If yes, answer the following questions for each person you marked in question 17 (up to six people).
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Service Member #1 |
Service Member #2 |
Service Member #3 |
Service Member #4 |
Service Member #5 |
Service Member #6 |
Service Member’s relationship to you: |
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Father |
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Brother/Sister |
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Aunt/Uncle |
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Grandparent |
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Other |
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(specify) |
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Has the Service Member experienced any of the following (select all that apply)? |
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18a.
Deployed in support of combat operations |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
18b. Was physically injured during combat operations? |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
18c. Developed combat stress symptoms/ difficulties adjusting following deployment, including PTSD, depression, or suicidal thoughts? |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
18d. Died or was killed? |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
Yes Don’t Know/Can’t Say |
End of Section One
Section
Two: Attitudes & Knowledge
Next, we’d like to ask you how you feel about substance use and sexual behavior, as well as what you know about HIV/AIDS. Again, your answers are private and will not be used to identify you.
The next few questions ask about HOW MUCH you think people RISK HARMING themselves physically or in other ways by using alcohol, tobacco, and drugs.
19. 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
20. 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
21. 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
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:
22. If they have oral sex without a condom or dental dam?
No risk
Slight risk
Moderate risk
Great risk
23. If they have vaginal sex without a condom?
No risk
Slight risk
Moderate risk
Great risk
24. If they have anal sex without a condom?
No risk
Slight risk
Moderate risk
Great risk
25. If they have sex under the influence of alcohol?
No risk
Slight risk
Moderate risk
Great risk
26. If they have sex while high on drugs?
No risk
Slight risk
Moderate risk
Great risk
27. If they share nonsanitized needles or works when using drugs? (“Works” refer to supplies used for injecting drugs)
No risk
Slight risk
Moderate risk
Great risk
The next questions ask more about your attitudes and beliefs about sex.
In your relationship with your PRIMARY (MAIN) partner, how confident are you that you could:
28. Refuse to have sex with your partner because you weren’t in the mood?
Not at all
A little
Somewhat
Very much
29. Ask your partner to wait while you got a condom or dental dam?
Not at all
A little
Somewhat
Very much
30. Tell your partner how to treat you sexually?
Not at all
A little
Somewhat
Very much
31. Refuse to engage in sexual practices you didn’t like?
Not at all
A little
Somewhat
Very much
32. Ask your partner to use a condom or dental dam?
Not at all
A little
Somewhat
Very much
33. 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
The next set of questions ask how likely you are to do certain behaviors in the future.
In the next 6 months, how likely are you...
34. To drink five or more alcoholic drinks in one sitting?
Not at all likely
A little likely
Somewhat likely
Very likely
35. To use any illegal drugs (including prescription drugs) to get high?
Not at all likely
A little likely
Somewhat likely
Very likely
36. To use injection drugs without a doctor’s orders, just to feel good or to get high?
Not at all likely
A little likely
Somewhat likely
Very likely
37. To use clean needles when injecting drugs?
I do not use injected drugs
Not at all likely
A little likely
Somewhat likely
Very likely
38. To practice safe sex?
Not intending to have sex during the next 6 months
Not at all likely
A little likely
Somewhat likely
Very likely
HIV/AIDS – What You Know
Please
indicate whether you think each of the following statements about
HIV/AIDS is true or false, or if you don’t know.
39. Only people who look sick can spread the HIV/AIDS virus.
True
False
Don’t know
40. Only people who have sexual intercourse with gay (homosexual) people get HIV/AIDS.
True
False
Don’t know
41. Birth control pills protect women from getting the HIV/AIDS virus.
True
False
Don’t know
42. There are drugs available to treat HIV that can lengthen the life of a person infected with the virus.
True
False
Don’t know
43. There is no cure for AIDS.
True
False
Don’t know
44. Young people under age 18 need their parents’ permission to get an HIV test.
True
False
Don’t know
The next questions ask about health care services.
45. Would you know where to go in your neighborhood to see a health care professional regarding HIV/AIDS or other sexually transmitted health issues?
Yes
No
46. Would you know where to go in your neighborhood to see a health care professional regarding a drug or alcohol problem?
Yes
No
47. Have you ever been tested for the HIV virus that causes AIDS?
Yes
No
48. If YES to Question 47, what type of HIV test was it?
Never
tested for HIV/AIDS
Oral (Mouth) test (OraSure/OraQuick Rapid Saliva Test or other)
Urine test
Blood test in a clinic or doctor’s office (Western Blot or other)
More than one test conducted in a clinic or doctor’s office
Home test kit
Don’t know
49. If YES to question 47, did you receive or go back to get your results?
Never
tested for HIV/AIDS
Yes
No
The following questions ask about your relationships.
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Thinking about all the people you know…
50. Are there any people you could go to when you want to talk about things having to do with your own health?
Yes, there are people I can talk with
No, there is no one I can talk with
51. Are there any people you could talk with about personal issues having to do with sex?
Yes, there are people I can talk with
No, there is no one I can talk with
52. Are there any people you could talk with about personal issues having to do with alcohol or drug use?
Yes, there are people I can talk with
No, there is no one I can talk with
53. Are there certain people you could go to if you need to talk about other personal matters that you wouldn’t tell just anyone?
Yes, there are people I can talk with
No, there is no one I can talk with
The next few questions ask about your religious or spiritual beliefs and how they may affect your daily life.
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54. 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
55. When you have problems or difficulties with your school (education), work, family, friends, or personal life, how often do you seek spiritual guidance and support?
Never
Rarely
Sometimes
Often
Almost always
56. How spiritual or religious would you say you are?
Not spiritual or religious at all
Not too spiritual or religious
Fairly spiritual or religious
Very spiritual or religious
End of Section Two
Section
Three: Behavior & Relationships
Cigarettes, Alcohol and Drugs
The
next two questions are about CIGARETTES
and OTHER TOBACCO PRODUCTS.
Think back over the past 30 days and record on how many days, if any, you used cigarettes and/or other tobacco products.
57. During the past 30 days, on how many days did you smoke part or all of a cigarette? (Includes menthol and regular cigarettes and loose tobacco rolled into cigarettes)
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11
days 23
days
58. During the past 30 days, on how many days did you use other tobacco products? (Includes any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe)
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
The next two questions are about ALCOHOL.
By alcohol, we mean BEER, WINE, WINE COOLERS, MALT BEVERAGES or HARD LIQUOR.
Different groups of people in the United States may use alcohol for religious reasons. For example, some churches serve wine during a church service. If you drink wine at church or for some other religious reason, do not count these times in your answers to the questions below.
Think back over the past 30 days and record on how many days, if any, you consumed alcohol.
59. During the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage?
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
60. During the past 30 days, on how many days did you have 4 or more drinks on the same occasion? [By 'occasion,' we mean at the same time or within a couple of hours of each other].
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
61. During the past 30 days, on how many days did you have 5 or more drinks on the same occasion? [By 'occasion,' we mean at the same time or within a couple of hours of each other].
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
62. During the past 30 days, on how many days have you been drunk or very high from drinking alcoholic beverages?
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
The next question is about MARIJUANA or HASHISH. Marijuana is sometimes called weed, blunt, hydro, grass, or pot. Hashish is sometimes called hash or hash oil.
Think back over the past 30 days and record on how many days, if any, you used marijuana or hashish.
63. During the past 30 days, on how many days did you use marijuana or hashish?
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
The next question is about OTHER ILLEGAL DRUGS, excluding marijuana or hashish.
These include substances like inhalants or sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, or shoe polish (used to feel good or get high), heroin, crack, or cocaine, methamphetamine, hallucinogens (drugs that cause people to see or experience things that are not real) such as LSD (sometimes called acid), Ecstasy (MDMA), PCP, peyote (sometimes called angel dust), and prescription drugs used without a doctor’s orders, just to feel good or to get high.
Think back over the past 30 days and record on how many days, if any, you used other illegal drugs.
64. During the past 30 days, on how many days did you use any other illegal drug?
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
Now we would like to ask about your use of several specific drugs during the past 30 days.
65. During the past 30 days, on how many days did you use cocaine or crack?
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
66. During the past 30 days, on how many days did you use methamphetamine? (Also called meth, crystal meth, crank, go, and speed)
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
67. During the past 30 days, on how many days have you used prescription drugs without a doctor’s orders, in order to feel good or to get high?
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
68. During the past 30 days, on how many days have you injected any drugs? (Count only injections without a doctor’s orders you used to feel good or to get high.)
0 days 12 days 24 days
1 day 13 days 25 days
2 days 14 days 26 days
3 days 15 days 27 days
4 days 16 days 28 days
5 days 17 days 29 days
6 days 18 days 30 days
7 days 19 days Don’t know
8 days 20 days or can’t say
9 days 21 days
10 days 22 days
11 days 23 days
69. During the past 30 days, how stressful have things been for you because of your use of alcohol or drugs?
I have not used alcohol or drugs in the past 30 days
Not at all
Somewhat
Considerably
Extremely
70. During the past 30 days, has your use of alcohol or drugs caused you to have emotional problems?
I have not used alcohol or drugs in the past 30 days
Not at all
Somewhat
Considerably
Extremely
The next few questions ask about the FIRST TIME you used a substance.
Think back whether you have EVER used any substances. If so, what was your age the FIRST TIME you used the following substances.
71. How old were you the first time you smoked part or all of a cigarette? (Includes menthol and regular cigarettes and loose tobacco rolled into cigarettes)
I
have never smoked part or all of a
cigarette
5 years old or younger 20 years old
6 years old 21 years old
7 years old 22 years old
8 years old 23 years old
9 years old 24 years old
10 years old 25 years old
11 years old 26 years old
12 years old 27 years old
13 years old 28 years old
14 years old 29 years old
15 years old 30 years old
16 years old Over 30
17 years old years old
18 years old Don’t know
19 years old or can’t say
72. How old were you the first time you used any other tobacco product? (Includes any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe)
I have never used any other tobacco products
5 years old or younger 20 years old
6 years old 21 years old
7 years old 22 years old
8 years old 23 years old
9 years old 24 years old
10 years old 25 years old
11 years old 26 years old
12 years old 27 years old
13 years old 28 years old
14 years old 29 years old
15 years old 30 years old
16 years old Over 30
17 years old years old
18 years old Don’t know
19 years old or can’t say
73. How old were you the first time you had a drink of an alcoholic beverage? (Includes beer, wine, wine coolers, malt beverages, and liquor) DO NOT include any time when you only had a sip or two from a drink.
I have never had a drink of an alcoholic beverage
5 years old or younger 20 years old
6 years old 21 years old
7 years old 22 years old
8 years old 23 years old
9 years old 24 years old
10 years old 25 years old
11 years old 26 years old
12 years old 27 years old
13 years old 28 years old
14 years old 29 years old
15 years old 30 years old
16 years old Over 30
17 years old years old
18 years old Don’t know
19 years old or can’t say
74.
How old were you the first time you used marijuana
or hashish? (Also
known as grass, pot, hash, or hash oil)
I
have never used marijuana or hashish
5 years old or younger 20 years old
6 years old 21 years old
7 years old 22 years old
8 years old 23 years old
9 years old 24 years old
10 years old 25 years old
11 years old 26 years old
12 years old 27 years old
13 years old 28 years old
14 years old 29 years old
15 years old 30 years old
16 years old Over 30
17 years old years old
18 years old Don’t know
19 years old or can’t say
75. How old were you the first time you used any other illegal drug?
I have never used any other illegal drugs
5 years old or younger 20 years old
6 years old 21 years old
7 years old 22 years old
8 years old 23 years old
9 years old 24 years old
10 years old 25 years old
11 years old 26 years old
12 years old 27 years old
13 years old 28 years old
14 years old 29 years old
15 years old 30 years old
16 years old Over 30
17 years old years old
18 years old Don’t know
19 years old or can’t say
Sexual Behavior
Now we’d like to ask you about your experience with sex. If you cannot remember what we mean by sex, please refer to the definitions on page 4. Remember, your answers are private.
76. Have you ever had sex (either vaginal, oral, or anal)?
Yes
No
77. Have you had oral sex in the past 30 days?
Yes
No
78. The last time you had oral sex, was it protected or unprotected?
I have never had oral sex
Protected
Unprotected
79. Have you had vaginal sex in the past 30 days?
Yes
No
80. The last time you had vaginal sex, was it protected or unprotected?
I have never had vaginal sex
Protected
Unprotected
81. Have you had anal sex in the past 30 days?
Yes
No
82. The last time you had anal sex, was it protected or unprotected?
I have never had anal sex
Protected
Unprotected
The next set of questions asks more specifically about your sexual behavior. Some questions refer to the past 3 months and others to your experience ever.
83. In the past 3 months, have you had sex with any men?
Yes
No
84. Are you a woman who has sex with men?
Yes
No
85. Are you a man who has sex with men?
Yes
No
86. In the past 3 months, have you had sex with any women?
Yes
No
87. Are you a man who has sex with women?
Yes
No
88. Are you a woman who has sex with women?
Yes
No
89. During the past 3 months, how many sexual partners have you had?
None 6 people
1 person 7 people
2 people 8 people
3 people 9 people
4 people 10 people or more
5 people
90. Have you ever had unprotected sex (vaginal, anal, or oral) with someone in exchange for money, drugs, or shelter?
Yes
No
91. In the past 3 months, have you had unprotected sex (vaginal, anal, or oral) with someone in exchange for money, drugs, or shelter?
Yes
No
92. Have you ever had unprotected sex (vaginal, anal, or oral) with a partner you know had, or suspected of having a sexually transmitted disease (STD)?
Yes
No
93. In the past 3 months, have you had unprotected sex (vaginal, anal, or oral) with a partner you know had, or suspected of having a sexually transmitted disease (STD)?
Yes
No
94. Have you ever had unprotected sex (vaginal, anal, or oral) with a partner you know had, or suspected of having HIV/AIDS?
Yes
No
95. In the past 3 months, have you had unprotected sex (vaginal, anal, or oral) with a partner you know had, or suspected of having HIV/AIDS?
Yes
No
96. Have you ever had unprotected sex (vaginal, anal, or oral) with someone whom you knew was, or suspected of being an injected drug user?
Yes
No
97. In the past 3 months, have you had unprotected sex (vaginal, anal, or oral) with someone whom you knew was, or suspected of being an injected drug user?
Yes
No
98. Have you ever had sex while you were under the influence of drugs or alcohol?
Yes
No
99. In the past 3 months, have you had sex while you were under the influence of drugs or alcohol?
Yes
No
The next few questions ask about abuse you might have experienced.
In the past 3 months, how often has anyone with whom you had an intimate relation, sexual or not…
100. Emotionally abused you (swore at you, called you negative names, kept you from seeing family or friends)?
Never
Rarely
Sometimes
Often
Very often
101. Physically abused you (slapped, beat, kicked, or choked you; threatened you with a knife or a gun)?
Never
Rarely
Sometimes
Often
Very often
102. Sexually abused you (forced you to have sex, physically hurt the sexual parts of your body)?
Never
Rarely
Sometimes
Often
Very often
103. Forced you to use drugs or alcohol?
Never
Rarely
Sometimes
Often
Very often
Family, Relationships and Work
104. Describe your current relationship status.
Single (never married)
Informally married or living with a permanent partner
Legally married
Separated
Divorced or broken up from an informal marriage
Widowed
105. With
whom do you live?
(Mark
all that apply)
Alone
With my mother
With my father
With my brother(s) and/or sister(s)
With my grandparent(s)
With other relatives or guardian
With my spouse or significant other
With my child or my children
With roommates
Other
106. Describe where you live.
In my own home or apartment
In a relative’s home
In a group home
In a foster home
Homeless or in a shelter
Other
107. At what age did you have your first child?
No children
9 to 13 years old
14 to 18 years old
19 to 25 years old
26 to 34 years old
35 years old or older
108. How many children under the age of 18 are living with you?
0
1 to 2
3 to 4
5 to 6
More than 6
109. If you have children, during the past 12 months, how many times have you talked with your children about the dangers or problems associated with the use of tobacco, alcohol, or drugs?
I don’t have any children
0 times
1 to 2 times
A few times
Many times
Don’t know or can’t say
110. Think about the household members that live with you right now. About how much income have you and/or your family members made in the last year before taxes? (Include child support and/or cash payments from the government, for example, welfare [TANF], SSI, or unemployment compensation)
$0–$10,000
$10,001–$20,000
$20,001–$30,000
$30,001–$40,000
$40,001–$50,000
$50,001–$60,000
More than $60,000
111. Do you have health care or medical insurance?
Yes
No
112. Would you be more or less likely to want to work for an employer that tests its employees for drug or alcohol use on a random basis? Would you say more likely, less likely, or would it make no difference to you? (Mark one)
More likely
Less likely
Would make no difference
Don’t know or can’t say
The next set of questions asks about your family’s relationships. |
113. I’m available when others in my family want to talk to me.
I don’t have any family
Not true
Sometimes true
Usually true
Always true
114. I listen to what other family members have to say, even when I disagree.
I don’t have any family
Not true
Sometimes true
Usually true
Always true
115. Members of my family ask each other for help.
I don’t have any family
Not true
Sometimes true
Usually true
Always true
116. Members of my family like to spend free time with each other.
I don’t have any family
Not true
Sometimes true
Usually true
Always true
117. Members of my family feel very close to each other.
I don’t have any family
Not true
Sometimes true
Usually true
Always true
118. We can easily think of things to do together as a family.
I don’t have any family
Not true
Sometimes true
Usually true
Always true
The next two questions ask about programs or classes you may have attended recently. |
119. In the past 30 days, have you been in any classes or programs where they talked about prevention of drug or alcohol abuse?
Yes
No
120. In the past 30 days, have you been in any classes or programs where they talked about preventing HIV/AIDS?
Yes
No
The last two questions ask about your experience with this survey. |
121. How comfortable was it for you to answer the questions in this survey?
Very comfortable
Somewhat comfortable
Somewhat uncomfortable
Very uncomfortable
122. How truthful were you when answering the questions?
Very truthful
Somewhat truthful
Somewhat untruthful
Very untruthful
YOU ARE DONE!
Thank you for your help!
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | HIV Cohort 6 Adult Baseline Questionnaire |
| Author | Calverton |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |
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