Appendix G. Baseline Surveys
(Male)
The baseline instrument was administered to both control and experimental participants at the first visit. It collects sociodemographic data, medical history, and detailed information on sexual behavior and use of drugs and alcohol.
Note: The female version of this survey is available in a separate document at
.
TAKE 5! Study
Baseline Male Questionnaire
Date of Birth: / / / /Month / Day / Year
Study ID:Date of Interview: / / / /
Month / Day / Year
Start Time: / :Hour : Minutes
Interviewer: / #1 / Sara Lieppe#2 / Priscilla Martinez
#3 / Ryan Swinney
#4 / Jennifer Perlman
#5 / Paula Lum
#6 / ______
EDIT / INITIALS / DATE
#1
#2
#3
Dissemination ProjectModule 9, Appendix G (male)Page G-1
INTRODUCTION: We are now ready to begin the interview. If you do not want to answer a certain question, you do not have to, but we would appreciate it if you would answer all of the questions that you can. As I mentioned, all of your answers are confidential. Your name will never be associated with any answer you give. Even the counselor, who you see after this interview, will not have access to any of the answers you tell me.
A.DEMOGRAPHICS
This first group of questions will help to give us an idea of your background.
A1.FILL IN FROM SCREENER: How would you best describe yourself?1=Female
2=Male
3=Transgender, born male but now female
4=Transgender, born female but now male
9=Declines to answer
A2.What is your current marital status?
1=Married
2=Member of an unmarried couple (include domestic partners)
3=Separated
4=Divorced
5=Single/Never married
6=Widowed
7=Other, specify: ______
8=Don’t know
9=Declines to answer
A3.What is the highest grade you completed in school?
1=Less than grade school (up to 8 years)
2=Less than high school (up to 12 years)
3=High school degree or equivalency (GED)
4=Technical or vocational school
5=Some college
6=College degree
7=Some graduate school
8=Graduate degree
9=Other, specify: ______
99= Declines to answer
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Dissemination ProjectModule 9, Appendix G (male)Page G-1
B.MEDICAL HISTORY
Now I am going to ask you some questions about health care and your medical history.
B1.In the LAST YEAR, have you received any health care from a clinic?1=Yes
2=No
8=Don’t know
9=Declines to answer
B2.(In the LAST YEAR, have you received any health care) from a private doctor’s office?
1=Yes
2=No
8=Don’t know
9=Declines to answer
B3.(In the LAST YEAR, have you received any health care) from an emergency room?
1=Yes
2=No
8=Don’t know
9=Declines to answer
B4.In the LAST YEAR, were you hospitalized?
1=Yes
2=No
8=Don’t know
9=Declines to answer
B5.(In the LAST YEAR) did you receive any alternative health care (i.e., acupuncture, chiropractic, herbalist, etc.)?
1=Yes
2=No
8=Don’t know
9=Declines to answer
B6.In the LAST YEAR, did you receive health care in any other setting? (i.e., at a shelter, on a mobile medical van, or at a needle exchange)? CHECK ALL THAT APPLY.
1=Yes, shelter
2=Yes, mobile medical van
3=Yes, needle exchange
4=Yes, specify: ______
5=No
8=Don’t know
9=Declines to answer
B7.How do you pay for health care services most of the time? Please listen to all the answers before choosing one. READ OPTIONS 1-7, CHECK ONLY ONE.
1=No payment
2=Sliding scale (made payment)
3=Full amount out-of-pocket
4=MediCal (SSI)
5=MediCare
6=Private insurance
7=Any other method of payment, specify: ______
8=Don’t know
9=Declines to answer
B8.In the LAST YEAR, have you ever had any of these symptoms?
READ ALL OPTIONS, CHECK ALL THAT APPLY.
1=
Yes / 2=
No /
B9.
If YES: For how long?
/ 1=One day
Or less / 2=
More than a day but
< 2 weeks / 3=
More than 2 weeks / B10.
Was this in the LAST 3 MOS?
1=Y / 2=N
a) / Discharge from the head of your penis
b) / Discharge from your rectum (butt)
c) / Pain or itching of the head of your penis
d) / Pain or burning with urination
e) / Swelling of your penis
f) / Pain or swelling of your testicles (balls)
g-l) / (SKIP QUESTIONS g-l)
m) / Nausea or vomiting
n) / Stomach pains or cramps
o) / Dark-colored urine
p) / Yellow eyes or skin
q) / Fever
r) / Unusual sweats
s) / Muscle aches
t) / Loss of appetite
u) / Skin rash
v) / Unintended weight loss >10 pounds
w) / Painful or large lymph glands (knots in your neck, armpits, groin)
IF NO TO ALL CONDITIONS IN B8 a-w, GO TO QUESTION B15, p.7
B11.Did you seek medical treatment for any of these symptoms?1=Yes
2=No / / GO TO B15, p.7
8=Don’t know /
9=Declines to answer /
B12.Where (did you seek medical treatment)? PROBE FOR NAME. CHECK ALL THAT APPLY.
a) / Private doctor’s office GO TO B15
b) / Clinic
c) / Emergency room GO TO B14
d) / Alternative health care (i.e., acupuncture, chiropractic, herbal)GO TO B15
e) / Alternative health setting (i.e., shelter, mobile van, needle exchange)GO TO B15
B13.Which clinic(s)?
a) / Castro/Mission Health Center (HC#1)
b) / Maxine Hall Health Center (HC#2)
c) / Silver Avenue Family Health Center (HC #3)
d) / Chinatown Public Health Center (HC#4)
e) / Ocean Park Health Center (HC#5)
f) / Potrero Hill Health Center
g) / Southeast Health Center
h) / Tom Waddell Clinic (Ivy Street)
i) / The City Clinic (STD Clinic on 7th St)
Other Clinics in SF
j) / Cole Street Youth Clinic
k) / Haight Ashbury Free Medical Clinic
l) / Larkin Street Youth Medical Clinic
m) / Lyon-Martin Women’s Health Services
n) / Mission Neighborhood Health Center
o) / Native American Health Center
p) / Northeast Medical Services (Stockton/Colombus)
q) / North of Market Senior Services (Turk/Leavenworth)
r) / San Francisco Free Clinic (Avenues)
s) / South Of Market Clinic
t) / St. Anthony Free Medical Clinic
SFGH Clinics
u) / SFGH Family Health Center (Ward 84)
v) / SFGH General Medical Clinic (1M)
w) / SFGH, Ward 86 (HIV/Oncology Clinic)
x) / SFGH, Ward 93 (Methadone Clinic)
y) / Other SFGH Clinic
Other Hospital Clinics
z) / California Pacific Medical Center
aa) / Davies Medical Center
bb) / Kaiser Permanente
cc) / St. Mary’s Hospital
dd) / St. Francis Hospital
ee) / St. Luke’s Hospital
ff) / UCSF/Mt. Zion Hospital
gg) / UCSF/Parnassus Campus
hh) / VA / Ft. Miley
ii) / Other clinic, specify: ______
jj) / Other clinic, specify: ______
B14.Which emergency rooms?
a) / California Pacific Medical Center
b) / Davies Medical Center
c) / Kaiser Permanente
d) / St. Mary’s Hospital
e) / St. Francis Hospital
f) / St. Luke’s Hospital
g) / UCSF/SFGH
h) / UCSF/Mt. Zion Hospital
i) / UCSF/Parnassus Campus
j) / Other ER, specify: ______
k) / Don’t know
B15.Has a doctor or nurse (or healthcare worker) EVERtold you that you have or may have any of the following infections? READ OPTIONS A-I. CHECK ALL THAT APPLY. USE OPTION J, IF UNSURE OF WHICH TYPE OF HEPATITIS.
EVER? / B16.
In the LAST 3 MONTHS? / B17.Deleted question
1=Y / 2=N / 1=Y / 2=N
a)Gonorrhea (“the clap”)
b)Chlamydia
c)Epididymitis (infection of testicles)
d)SKIP QUESTION
e)Trichomonas (“trick”)
f)Syphilis (“lues”)
g)Genital herpes
h)Genital warts
i)Hepatitis B
j)Hepatitis C
k)Hepatitis, type unknown
B18.Have you EVER received a transfusion of blood or blood products?
1=Yes
2=No / / GO TO B20
on next page
8=Don’t know /
9=Declines to answer /
B19.When was the FIRST TIME?
Month Year
9998= Don’t know
9999= Declines to answer
B20.Have you EVER been accidentally stuck with a needle that may have been previously used by someone else? (Example: a needle lying on the ground, at work, or in the trash)
1=Yes
2=No / / GO TO B22
8=Don’t know /
9=Declines to answer /
B21.When was the most RECENT TIME?
Month Year
9998= Don’t know
9999= Declines to answer
B22.Have you EVER used a razor (for shaving) that someone else had already used?
1=Yes
2=No / / GO TO B22b
8=Don’t know /
9=Declines to answer /
B22a. When was the most RECENT TIME?
Month Year
9998= Don’t know
9999= Declines to answer
B22b. Have you EVER used a toothbrush that someone else had already used?
1=Yes
2=No / / GO TO “Hepatitis” on next page
8=Don’t know /
9=Declines to answer /
B22c. When was the most RECENT TIME?
Month Year
9998= Don’t know
9999= Declines to answer
Hepatitis
These next questions are about viral hepatitis, an infection of the liver. There are several types. First, I’m going to ask you about hepatitis C, which is passed most easily by blood and less easily by sex. Then I will ask you about hepatitis B, which can be passed easily by both blood and sex.
B23.Have you EVER been tested for the hepatitis Cvirus?1=Yes
2=No / / GO TO “Hepatitis B” on next page
8=Don’t know /
9=Declines to answer /
B24.How many times (have you been tested for hepatitis C)?
B25.Where have you been tested? CHECK ALL THAT APPLY. PROBE FOR MORE THAN ONE ANSWER.
a)Hospital, name: ______
b)Community clinic, name: ______
c)Alternative test site, name: ______
d)Private facility or private doctor
e)Mobile van
f)Planned Parenthood
g)Jail or prison
h)Research study
i)Other, specify: ______
j)Don’t know
k)Declines to answer
B26.When was your last hepatitis C test?
Month / Year
9998= Don’t know
9999= Declines to answer
B27.What was your last hepatitis C test result? IF UNSURE, READ OPTIONS 4-6; CHECK ONLY ONE.
1=HCV positive / / GO TO “Hepatitis B” on next page
2=HCV negative /
3=Results were indeterminate /
4=(Unsure) Did not return for result
5=(Unsure) Returned for post-test counseling but chose not to receive results
6=(Unsure) Don’t remember the result
9=Declines to answer
B28.When was the last time you received a (hepatitis C test) result you were sure of?
Month / Year (CODE NEVER=00/00) IF “NEVER”, GO TO B30
9998= Don’t know
9999= Declines to answer
B29.What was the result (of the last hepatitis C test you know the result)? CHECK ONLY ONE.
1=Positive
2=Negative
3=Results were inconclusive (indeterminate)
9=Declines to answer
Hepatitis B
B30.Have you EVER been tested for the hepatitis B virus?1=Yes
2=No / / GO TO “Hepatitis B Immunizations” on next page
8=Don’t know /
9=Declines to answer /
B31.How many times (have you been tested for hepatitis B)?
B32.Where have you been tested? CHECK ALL THAT APPLY. PROBE FOR MORE THAN ONE ANSWER.
a)Hospital, name: ______
b)Community clinic, name: ______
c)Alternative test site, name: ______
d)Private facility or private doctor
e)Mobile van
f)Planned Parenthood
g)Jail or prison
h)Research study
i)Other, specify: ______
j)Don’t know
k)Declines to answer
B33.When was your last hepatitis B test?
Month / Year
9998= Don’t know
9999= Declines to answer
B34.What was your last hepatitis B test result? IF UNSURE, READ OPTIONS 4-6; CHECK ONLY ONE.
1=HBV positive (exposed or immune) / / GO TO “Hepatitis B Immunizations”
2=HBV negative /
3=Results were indeterminate /
4=(Unsure) Did not return for result
5=(Unsure) Returned for post-test counseling but chose not to receive results
6=(Unsure) Don’t remember the result
9=Declines to answer
B35.When was the last time you received a (hepatitis B test) result you were sure of?
Month / Year(CODE NEVER =00/00) IF “NEVER”, GO TO B37
9998= Don’t know
9999= Declines to answer
B36.What was the result (of the last hepatitis B test you do know the result)? CHECK ONLY ONE.
1=Positive
2=Negative
3=Results were inconclusive (indeterminate)
9=Declines to answer
Hepatitis B Immunizations
Hepatitis B can be prevented with a series of three immunizations.
B37.Have you ever been vaccinated against the hepatitis B virus?1=Yes
2=No / / GO TO “HIV/AIDS” next page
8=Don’t know /
9=Declines to answer /
B38.Where were you vaccinated? CHECK ALL THAT APPLY. PROBE FOR MORE THAN ONE ANSWER.
a)Private doctor’s office
b)STD Clinic (i.e., The City Clinic)
c)Community-based (or hospital) clinic
d)College or school clinic
e)Health maintenance organization (HMO)
f)Emergency room (in a hospital)
g)Hospital, inpatient
h)Research study, specify: ______
i)Somewhere else, specify: ______
j)Don’t know
k)Declines to answer
B39.What year were you vaccinated? IF COMPLETED ALL 3 SHOTS, OBTAIN DATE SERIES COMPLETED. IF LESS THAN 3 SHOTS, OBTAIN DATE FOR LAST SHOT RECEIVED.
Year
9998= Don’t know
9999= Declines to answer
B40.How many TOTAL shots did you receive?
HIV and AIDS
These next questions are about HIV, the virus that causes AIDS.
B41.How many times have you been tested for HIV?IF ZERO, GO TO SECTION C, p. 15
B42.Where were you tested? CHECK ALL THAT APPLY. PROBE FOR MORE THAN ONE ANSWER.
a) / San Francisco General Hospital
b) / San Francisco City Clinic
c) / Other public facility or clinic, name: ______
d) / Alternative test site (e.g., AIDS Health Project)
e) / Jail or prison
f) / Mobile van
g) / Private facility or private doctor
h) / Planned Parenthood
i) / Research study
j) / Somewhere else, specify: ______
k) / Don’t know
l) / Declines to answer
B43.When was your last HIV test?
Month / Year
9998= Don’t know
9999= Declines to answer
B44.What was your last HIV test result? IF UNSURE, READ OPTIONS 4-6; CHECK ONLY ONE.
1=HIV positive / / GO TO SECTION C next page
2=HIV negative /
3=Results were indeterminate /
4=(Unsure) Did not return for result
5=(Unsure) Returned for post-test counseling but chose not to receive results
6=(Unsure) Don’t remember the result
9=Declines to answer
B45.When was the last time you received a (HIV test) result you were sure of?
Month / Year (CODE NEVER=00/00) IF NEVER, GO TO SECTION C, p 15
9998= Don’t know
9999= Declines to answer
B46.What was the result (of the last HIV test you do know the result)? CHECK ONLY ONE.
1=Positive
2=Negative
3=Results were inconclusive (indeterminate)
9=Declines to answer
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Dissemination ProjectModule 9, Appendix G (male)Page G-1
B2.REPRODUCTIVE HEALTH
GO TO SECTION C, next page
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Dissemination ProjectModule 9, Appendix G (male)Page G-1
C.SEXUAL BEHAVIOR
This next section is about your experiences with sex. By sex I mean oral sex (penis in mouth), vaginal sex (penis in vagina) and anal sex (penis in butt).
You may have done the things that I am asking about often or not at all, or perhaps only tried them once or twice. Please remember that all of your answers are confidential. Also, please remember: Some of these questions may be difficult, but I’d really appreciate it if you would be as honest as possible.
(INTERVIEWER: YOU MAY INSERT RESPONSE FROM SCREENER IF PARTICIPANT WAS SCREENED BY YOU.)
C1.Have you EVER had sex with another person (OR: has a person ever had sex with you)?1=Yes
2=No / / GO TO SECTION G pg. 41
8=Don’t know /
9=Declines to answer /
C2.During your whole lifetime, have you had sex with only men, only women, or with both men and women?
1=Men only
2=Women only
3=Both men and women
9=Declines to answer
C3.How old were you the FIRST TIME you had vaginal, anal or oral sex with another person?
C4.Which of the following best describes your CURRENT sexual orientation? Please listen to all the answers before choosing one. READ OPTIONS 1-5. CHECK ONLY ONE. READ ITALICS ONLY FOR CLARIFICATION.
1=Straight only (exclusively heterosexual)
2=Mostly straight (primarily heterosexual)
3=Bisexual (equally heterosexual and homosexual)
4=Mostly gay (primarily homosexual)
5=Gay only (exclusively homosexual)
8=Don’t know
9=Declines to answer
INTERVIEWER: SEE QUESTION C2. IF SEX WITH “MEN ONLY”, SKIP TO SECTION E p. 26
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Dissemination ProjectModule 9, Appendix G (male)Page G-1
D.SEX WITH WOMEN
So now let’s talk about sex with women. By “sex” with women, I am talking only about vaginal sex (penis in vagina), anal sex (penis in butt), and oral sex (penis in mouth).
D1.With approximately how many different women in your lifetime have you ever had sex?IF RESPONDENT CANNOT RECALL, ASK: “WHAT WOULD YOU ESTIMATE?” (99998=DON’T KNOW; 99999=DECLINES TO ANSWER)
# Lifetime female sex partners
These next questions are about sex during the LAST 3 MONTHS. To help you remember, the date three months ago was: ______/ ______
(month) / (day)
D2.Since MM/DD, with approximately how many different women have you had sex?IF RESPONDENT CANNOT RECALL, USE GUIDE BELOW.
# 3-month female sex partners (IF ZERO, GO TO SECTION E, PG 26.)
- If you have had about one partner a day, that would be about 90 partners.
- If you have had two or three partners a week, that would be about 30 partners.
- If you have had about one partner a week, that would be about 12 partners.
- If you have had one partner a month, that would be 3 partners.
D3.Of these ____ (NUMBER IN D2), how many injected drugs a doctor did not prescribe for them (including street drugs, steroids or hormones)?
D4.Since MM/DD, what kind, if any, of birth control (family planning) methods have you or any of your female partners used? PROBE FOR MORE THAN ONE ANSWER. CHECK ALL THAT APPLY.
a) / Oral contraceptive pills
b) / Injections (e.g. Depo-Provera)
c) / Intrauterine device or IUD
d) / Diaphragm, cervical cap or sponge
e) / Spermicidal foam
f) / Spermicidal suppository
g) / Tubal ligation (tubes tied)
h) / Female condoms
i) / Male condoms
j) / Rhythm method (“safe days”)
k) / W Withdrawal (before ejaculation)
l) / No birth control
m) / Declines to answer
D5.In the LAST 3 MONTHS, have you had any female sex partners who were planning or trying to become pregnant?
1=Yes
2=No
8=Don’t know
9=Declines to answer
D6.In the NEXT 3MONTHS, are any of your female sex partners planning to become pregnant?
1=Yes
2=No
8=Don’t know
9=Declines to answer
Steady, casual, exchange, and new female sexual partners
These next questions are about sex with different types of female partners during the LAST 3 MONTHS. These types of partners are:
- A STEADY PARTNER is a woman you have a close, ongoing sexual relationship with more than anyone else. (Even if the relationship has since ended).
- EXCHANGE PARTNERS are women you have traded sex with in exchange for things you needed or they needed like money, drugs, food, or shelter. (That is, if the trade did not occur, then you would not have had sex.)
- CASUAL PARTNERS are women you have sex with occasionally (or anonymously) and who you do not consider a steady partner or an exchange partner.
D1.STEADY FEMALE PARTNERS
First let’s talk about steady partners.
D1.1Since MM/DD, are there any women you’ve considered steady partner/s?1=Yes
2=No / / GO TO SECTION D2
“Exchange Female Partners” p.20
8=Don’t know /
9=Declines to answer /
D1.2How many?
# Steady female sex partners in last 3 months
D1.3Of these, how many were new, partners you had sex with for the first time in the last 3 months?
# New steady female sex partners
INTERVIEWER: FOR THE FOLLOWING QUESTIONS, USE GUIDE BELOW IF RESPONDENT CANNOT RECALL FREQUENCY OF SEXUAL EPISODES. Code 0000 if never, 9998 if don’t know, 9999 if declined to answer.