Appendix H. Follow-Up Surveys (Female)

Appendix H. Follow-Up Surveys
(Female)

The follow-up instrument was administered to both control and experimental participants at six months, just prior to the final testing session. It collects the same information as the baseline survey (see Appendix G), but focuses on the last three months.

Note: The male version of this instrument is available in a separate document at http://uarp.ucop.edu/ca_collaborations/modules/module9a_app.html.

TAKE 5! STUDY

Follow-up Female Questionnaire

Date of Birth: / / / /

Month / Day / Year

Study ID:
Date of Interview: / / / /

Month / Day / Year

Follow-up Interview Type

/ 3-Month
6-Month
Start Time: / :

Hour : Minutes

Interviewer: / #1 / Sara Lieppe
#2 / Priscilla Martinez
#3 / Ryan Swinney
#4 / Jennifer Perlman
#5 / Paula Lum
#6 / Rachel Long
#7
#8
EDIT / INITIALS / DATE
#1
#2
#3

Dissemination Project Module 9, Appendix H (female) Page H-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 will not have access to any of the answers you tell me.

The format of this interview is similar to the previous interview, except that I will only be asking about the LAST 3 MONTHS. To help you remember, the date 3 months ago was MM/DD.

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

Confidential

Dissemination Project Module 9, Appendix H (female) Page H-51

B.  MEDICAL HISTORY

Now I am going to ask you some questions about your health and health care since your last interview.

B1.  In the LAST THREE MONTHS, 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 THREE MONTHS, 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 THREE MONTHS, 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 THREE MONTHS, were you hospitalized?
1=  Yes
2=  No
8=  Don’t know
9=  Declines to answer
B5.  (In the LAST THREE MONTHS) 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 THREE MONTHS, 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 3 MONTHS, have you had any of these symptoms?
READ ALL OPTIONS, CHECK ALL THAT APPLY.
1=
Yes / 2=
No /

B9. 

If YES: For how long? ààà

/ 1=
One day
Or less / 2=
More than a day but
< 2 weeks / 3=
More than 2 weeks / B10. DELETED QUESTION
a-f / (SKIP QUESTIONS a-f)
g)  / New discharge from your vagina
h)  / New discharge from your rectum
i)  / Foul vaginal odor
j)  / Irregular spotting or bleeding
k)  / Severe pain or burning with urination
l)  / Severe pain or burning with sex
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 g-w, GO TO QUESTION B15, p.7

B11.  Did you seek medical treatment for any of these symptoms?
1=  Yes
2=  No / àà / GO TO B15, p.7
8=  Don’t know / àà
9=  Declines to answer / àà
B12.  Where (did you seek medical treatment)? PROBE FOR NAME. CHECK ALL THAT APPLY.
a)  / Private doctor’s office àà GO TO B15
b)  / Clinic
c)  / Emergency room àà GO TO B14
d)  / Alternative health care (i.e., acupuncture, chiropractic, herbal) àà GO TO B15
e)  / Alternative health setting (i.e., shelter, mobile van, needle exchange) àà 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.  In the LAST 3 MONTHS, has a doctor or nurse (or healthcare worker) told you that you have or may have any of the following infections? READ OPTIONS A-J. CHECK ALL THAT APPLY. USE OPTION K, IF UNSURE OF WHICH TYPE OF HEPATITIS.
Deleted question / B16.  In the LAST 3 MONTHS (as new info)? / B17.  Deleted question
1=Y / 2=N
a)  Gonorrhea (“the clap”)
b)  Chlamydia
c)  SKIP QUESTION
d)  Pelvic Inflammatory Disease (PID)
e)  Trichomonas (“trick”)
f)  Syphilis (“lues”)
g)  Genital herpes
h)  Genital warts
i)  Hepatitis B
j)  Hepatitis C
k)  Hepatitis, type unknown
B18.  In the LAST 3 MONTHS, have you received a transfusion of blood or blood products?
1=  Yes
2=  No / àà / GO TO B20
on next page
8=  Don’t know / àà
9=  Declines to answer / àà
B19.  When was this? (IF MORE THAN ONE TRANSFUSION, ENTER EARLIEST DATE)
Month Year
9998= Don’t know
9999= Declines to answer
B20.  In the LAST 3 MONTHS, have you 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 / àà / GO TO B22
8=  Don’t know / àà
9=  Declines to answer / àà
B21.  When was the most RECENT TIME?
Month Year
9998= Don’t know
9999= Declines to answer
B22.  In the LAST 3 MONTHS, have you used a razor (for shaving) that someone else had already used?
1=  Yes
2=  No / àà / GO TO B22b
8=  Don’t know / àà
9=  Declines to answer / àà
B22a. When was the most RECENT TIME?
Month Year
9998= Don’t know
9999= Declines to answer
B22b. In the LAST 3 MONTHS, have you used a toothbrush that someone else had already used?
1=  Yes
2=  No / àà / GO TO “Hepatitis” on next page
8=  Don’t know / àà
9=  Declines to answer / àà
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.  In the LAST 3 MONTHS, have you been tested for the hepatitis C virus outside of this study? DO NOT INCLUDE TESTING DONE WITH TAKE 5 STUDY.
1=  Yes
2=  No / àà / GO TO “Hepatitis B” on next page
8=  Don’t know / àà
9=  Declines to answer / àà
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 / àà / GO TO “Hepatitis B” on next page
2=  HCV negative / àà
3=  Results were indeterminate / àà
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.  In the LAST 3 MONTHS, have you been tested for the hepatitis B virus outside of this study? DO NOT INCLUDE TESTING DONE WITH TAKE 5 STUDY.
1=  Yes
2=  No / àà / GO TO “Hepatitis B Immunizations” on next page
8=  Don’t know / àà
9=  Declines to answer / àà
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) / àà / GO TO “Hepatitis B Immunizations”
2=  HBV negative / àà
3=  Results were indeterminate / àà
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.  In the LAST 3 MONTHS, have you been vaccinated against the hepatitis B virus outside of this study? DO NOT INCLUDE VACCINES RECEIVED WITH TAKE 5 STUDY.
1=  Yes
2=  No / àà / GO TO “HIV/AIDS” next page
8=  Don’t know / àà
9=  Declines to answer / àà
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.  SKIP QUESTION
B40.  How many TOTAL shots did you receive in the last 3 months?

HIV and AIDS

These next questions are about HIV, the virus that causes AIDS.