Form 1 HIV Risk Factor Questionnaire English

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HIV risk factorquestionnaire (English Translation)

RECIPIENT EPIDEMIOLOGY AND DONOR EVALUATION STUDY-III (REDS-III)

HIV RISK FACTOR QUESTIONNAIRE

Date: __ __/__ __/__ __ __ __ (D D/ M M / Y Y Y Y)

Study identification number: __ - __ __ __ __ __ __ __ - __

RETROVIRUS EPIDEMIOLOGY DONOR STUDY-III (REDS-III)

HIV RISK FACTOR QUESTIONNAIRE

Date: __ __/__ __/__ __ __ __ (D D/ M M / Y Y Y Y)

Study identification number: __ - __ __ __ __ __ __ __ - __

Instructions: Please answer each of the following questions about your health, lifestyle, and blood donation history. For each question, provide a response unless directed to skip to another question further down in the questionnaire. It will take approximately 20 minutes to complete these questions.

1. Your Background

When were you born?	__ __ __ __ (year)
What is your gender?	Female Male
What is your place of birth?	Province:____________________________ City:________________________________ County:______________________________
What is your ethnicity?	Han Hui Uygur Man Dai Zhuang Other, specify ______________
What is your current occupation? 5a. Have you ever provided special services at entertainment business (including night clubs, private clubs, night bar, Karaoke clubs)?	Worker Farmer who works at hometown Farmer or worker working out of town Service or business Education/research/government Military/Police Medicine/Health care Student Company employee Self-employed Other, specify _____________ Yes (please describe)__________________________ No Unknown
What is the highest level of education you have received?	Primary school or less Junior high school High School or vocational school Associate degree Bachelor’s degree Graduate level degree Other, specify _____________
What is your marital status?	Never married Married or co-habiting Divorced Separated Widowed Other, specify _____________

2. History of Blood Donation & Infection Risks

8. How many times have you donated blood?

__ __ time (s)ANSWER QUESTION 8a-8c

Please list the most recent three blood donations indicating the year and type of blood donation for each.(If you have donated blood more than 3 times, please list the most recent three):

Donation	Year	Type of Donation
8a. Most recent donation	__ __ __ __	Whole blood donation Apheresis donation
8b. Next most recent donation	__ __ __ __	Whole blood donation Apheresis donation
8c. Next most recent donation	__ __ __ __	Whole blood donation Apheresis donation

9. How much do you agree or disagree with each of the statements (9a-9c) below:

Statement	Do not agree at all	Disagree a little	Agree a little	Agree very much
9a. It’s important that I received blood test results from blood donation.
9b. I think blood donation is a good, fast, anonymous way to get my blood test result.
9c. One of my reasons for donating blood is to find out if I have HIV and/or hepatitis infection.

Have you ever been told that you are at risk for spreading diseases through your blood? 10a. What kind of diseases? (Mark all that apply) 10b. When was the last time you were told so?	YesANSWER QUESTION 10a No Skip to Q11 UnknownSkip to Q11 Hepatitis A Hepatitis B Hepatitis C Syphilis/Gonorrhea HIV/AIDS Other, specify __________ Unknown Within 3 days up to 1 month Within 1-3 months Within 3-6 months From 6 months to less than 1 year 1 year ago Unknown
Did you ever receive notification from blood center about your infection status? 11a. Before your most recent donation, had you ever received notification from blood center about your infection status (excluding any such notification after your most recent blood donation)? 11b. Had you sought further testing or health care according to the instruction of the notification (excluding any such notification after your most recent blood donation)? 11c. Are you planning to seek further testing or health care according to the instruction of the notification?	YesANSWER QUESTION 11a-11c No Skip to Q12 UnknownSkip to Q12 Yes No Unknown Yes No Unknown Yes No Unknown
Before your most recent donation, had you ever been permanently deferred as a blood donor? 12a. For what reason were you permanently deferred?(Mark all that apply)	YesANSWER QUESTION 12a NoSKIP TO 13 UnknownSKIP TO 13 Hepatitis B Hepatitis C Syphilis HIV Didn’t pass Physical Exam, specify ________ Didn’t pass blood Test, specify __________ Other, specify ______________________
Before your most recent donation, had you ever been temporarily deferred as a blood donor? 13a. For what ineligibility were you temporarily deferred?(Mark all that apply)	YesANSWER QUESTION 13a NoSKIP to Q 14 UnknownSKIP to Q14 HBV rapid test ALT Hemoglobin (Hb) level Blood pressure Heart rate Body Weight Fasting Other, specify ______________________

3. Health Condition History

Have you ever received acupuncture treatment? 14a. In the past6 months, did you have acupuncture?	Yes ANSWER QUESTION 14a NoSKIP TO 15 UnknownSKIP TO 15 Yes No Unknown
In the past 6 months, did you have any injection (including intravenous [IV] and intramuscular [IM] injections)? 15a. How many times did you have injection(s)?	Yes ANSWER QUESTION 15a NoSKIP TO 16 UnknownSKIP TO 16 __ __ times
Have you had any finger sticks (excluding the one prior to making a donation)? 16a. In the past 6 months, did you have finger sticks (other than the one prior to making a donation)?	YesANSWER QUESTION 16a NoSKIP TO 17 UnknownSKIP TO 17 Yes No Unknown

17. When you had acupuncture, finger sticks, or injections, were needles and syringes used disposable?

Were needles and syringes used disposable?	Seldom	Sometimes	Often	Always	Unknown
a. Acupuncture
b. Finger sticks
c. Injections

In the past 6 months, have you ever visited the following medical facilities?(Mark all that apply) 18a. What kind of treatment did you receive from the above medical facilities?(Mark all that apply)	Yes, county hospitalANSWER QUESTION 18a Yes, town hospitalANSWER QUESTION 18a Yes, community hospitalANSWER QUESTION 18a Yes, village clinicANSWER QUESTION 18a Yes, private outpatient clinicANSWER QUESTION 18a Yes, other, please specifyANSWER QUESTION 18a No SKIP TO 19 UnknownSKIP TO 19 Intravenous (IV) or intramuscular (IM)injection Therapeutic transfusion Outpatient surgeries (including anesthesia, removal of sebaceous cyst, wound suture etc.) Dental care Pediatrician visit or accompany for someone else Other, please specify__________
Have you ever had in-patient medical surgery? 19a. In the past 6 months, did you have in-patient medical surgery?	YesANSWER QUESTION 19a NoSKIP TO 20 UnknownSKIP TO 20 Yes No Unknown
Have you ever had out-patient medical surgery? 20a. In the past 6 months, did you have out-patient medical surgery?	Yes ANSWER QUESTION 20a NoSKIP TO 21 UnknownSKIP TO 21 Yes No Unknown
Have you ever had cosmetic surgery (e.g. laser, eye/lip surgery, collagen injection, dermal abrasion)? 21a. In the past 6 months, did you have cosmetic surgery?	Yes ANSWER QUESTION 21a NoSKIP TO 22 UnknownSKIP TO 22 Yes No Unknown
Have you ever received a blood transfusion? 22a. How many times did you have blood transfusions? 22b. Year of your first time of blood transfusion? 22c. Year of your last time of blood transfusion?	YesANSWER22a-22c NoSKIP TO 23 UnknownSKIP TO 23 __ __ times __ __ __ __ (year) __ __ __ __ (year)
Have you ever had any dental cleaning? 23a. In the past 6 months, did you have dental cleaning?	YesANSWER QUESTION 23a NoSKIP TO 24 UnknownSKIP TO 24 Yes No Unknown
Have you ever had any dental surgery, such as root canal treatment or tooth extraction? 24a. In the past 6 months, did you have dental surgeries?	YesANSWER QUESTION 24a NoSKIP TO 25 UnknownSKIP TO 25 Yes No Unknown
Have you ever had any endoscopy (such as gastroscopy and colonoscopy)? 25a. In the past 6 months, did you have endoscopies?	YesANSWER QUESTION 25a NoSKIP TO 26 UnknownSKIP TO 26 Yes No Unknown
Have you ever been previously diagnosed with hepatitis? 26a. What type(s) of hepatitis did you have (please choose all that apply)?	YesANSWER QUESTION 26a NoSKIP TO 27 UnknownSKIP TO 27 Hepatitis A Hepatitis B Hepatitis C Other, specify _____________ Unknown
Have you ever been previously diagnosed with syphilis, gonorrhea, or any other sexually transmitted disease?	Yes No Unknown
Have any of your family members had hepatitis?	Yes No Unknown?
Have any of your family members had HIV/AIDS?	Yes No Unknown
Have you ever had household contact with someone with HIV/AIDS? 30a. In the past 6 months, did you have household contact with someone with HIV/AIDS?	YesANSWER QUESTION 30a NoSKIP TO 31 UnknownSKIP TO 31 Yes No Unknown

4. Drug Use History

Have you ever used needles to shoot (or take) street drugs? 31a. How long have you shot (or taken) street drugs? 31b. How many times per month did you shoot (or take) street drugs? 31c. Have you ever shared needles or syringes with others to inject street drugs? 31d. In the past 6 months, did you ever use needles to shoot (or take) street drugs?	YesANSWER QUESTIONS 31a-31d NoSKIP TO 32 UnknownSKIP TO 32 __ __ years __ __ times/month Yes No Unknown Yes No Unknown
Have you ever used illegal oral or intranasal drugs without doctor’s prescription? 32a. In the past 6 months, did you use illegal oral or intranasal drugs without doctor’s prescription	YesANSWER QUESTION 32a NoSKIP TO 33 UnknownSKIP TO 33 Yes No Unknown
Have you ever lived with a person who was an intravenous drug user? 3a. In the past 6 months, did you live with a person who was an intravenous drug user?	YesANSWER QUESTION 33a NoSKIP TO 34 UnknownSKIP TO 34 Yes No Unknown
Are any of your close friends or family member’s intravenous drug users?	Yes No Unknown

5. Sexual History

The next section of questions will ask you about your sexual experiences. In these questions, include only those people you have had oral, vaginal, or anal sex with. Do not include people that you have just kissed. Please note that for the next few questions the term "sex" refers to any of the following activities, whether or not a condom or other protection was used: Vaginal sex (contact between penis and vagina), Oral sex (mouth or tongue on someone’s vagina, penis, or anus), Anal sex (contact between penis and anus).

Have you had more than 2 concurrent sexual partners of the opposite sex? 35a1. In your lifetime, how many heterosexual partners did you have? 35a2. In the past 6 months, how many heterosexual partners did you have? 35b1. How often do you or your sex partner use a condom when you have sex with your heterosexual partner? 35b2. In the past 6 months, how often do you or your sex partner use a condom when you have sex with your heterosexual partner?	YesANSWER QUESTIONS35a1-35b2 NoSKIP TO 36 UnknownSKIP TO 36 1-2 3-4 5-7 8-10 >10 1-2 3-4 5-7 8-10 >10 Never Sometimes Half of time Most of time Always Never Sometimes Half of time Most of time Always
(FOR MALE RESPONDENTS ONLY) In your lifetime, have you ever had sex with another male? 36a1. In your lifetime, how many times did you have sex with males? 36a2. In your lifetime, how many male partners have you had sex with? 36a3. In your lifetime, how often do you or your sex partner use a condom when you have sex with male partner? 36b1. In the past 6 months, how many times did you have sex with males? 36b2. In the past 6 months, how many male partners have you had sex with? 36b3. In the past 6 months, how often do you or your sex partner use a condom when you have sex with male partner?	YesANSWERQUESTIONS 36a1-36b3 NoSKIP TO 37 UnknownSKIP TO 37 1-2 3-5 6-10 >10 1-2 3-5 6-10 >10 Never Sometimes Half of time Most of time Always 1-2 3-5 6-10 >10 1-2 3-5 6-10 >10 Never Sometimes Half of time Most of time Always
Have you ever paid or received money or other forms of remuneration for having sex? 37a. In the past 6 months, have you paid or received money or other forms of remuneration for having sex?	YesANSWER QUESTIONS37a NoSKIP TO 38 UnknownSKIP TO 38 Yes No Unknown
Have you ever had a sex partner who was an intravenous drug user? 38a. In the past 6 months, did you have a sex partner who was an intravenous drug user?	YesANSWER QUESTION 38a NoSKIP TO 39 UnknownSKIP TO 39 Yes No Unknown
In your lifetime, have you ever had a sex partner who had a positive test for syphilis, gonorrhea, or any other sexually transmitted disease? 39a. In the past 6 months, did you have a sex partner who had a positive test for syphilis, gonorrhea, or any other sexually transmitted disease?	YesANSWER QUESTION 39a NoSKIP TO 40 UnknownSKIP TO 40 Yes No Unknown
In your lifetime, have you ever had a sex partner who had been diagnosed with HIV/AIDS? 40a. In the past 6 months, did you have a sex partner who had been diagnosed with HIV/AIDS?	YesANSWER QUESTION 40a NoSKIP TO 41 UnknownSKIP TO 41 Yes No Unknown
In your lifetime, have you had sexual contact with anyone who received blood transfusion? 41a. In the past 6 months, did you have sexual contact with anyone who received blood transfusion?	YesANSWER QUESTION 41a NoSKIP TO 42 UnknownSKIP TO 42 Yes No Unknown

6. Other Risk Factors

Have you ever had contact with human blood and other human body fluids in your workplace? 42a. In the past 6 months did you ever have contact with human blood and other human body fluids in your workplace?	YesANSWER QUESTION 42a NoSKIP TO 43 UnknownSKIP TO 43 Yes No Unknown
Have you ever had a tattoo? 43a. In the past 6 months, did you have a tattoo?	YesANSWER QUESTION 43a NoSKIP TO 44 UnknownSKIP TO 44 Yes No Unknown
Have you ever had your ears or other body parts pierced? 44a. In the past 6 months, did you have your ears or other body parts pierced?	YesANSWER QUESTION 44a NoEND UnknownEND Yes No Unknown

Thank you very much for your participation!

Thank you for your contribution to our blood safety research!