COMMUNITY DEMOGRAPHIC AND RISK SURVEY

For administrative use
Date: / Site ID:
Administered by:

Instructions: Thank you for taking the time to complete this survey. Your help may provide new information that will lead to better ways to prevent HIV/AIDS. This survey is completely anonymous. Please do not put your name anywhere on it. Please answer all questions honestly and try not to skip any questions. By completing these questions, you give consent to participate in this survey.

1.What is yourbirth date?____ / ____ / ____(month/day/year)

2.In what state do you currently live? ______

3.Were you born as a male or a female?

Male

Female

Don’t Know

Did Not Ask

Refused to Answer

4.Would you describe yourself as(i.e., what is your current gender):

Male

Female

Transgender – Male to Female

Transgender – Female to Male

Don’t Know

Did Not Ask

Refused to Answer

5.What best describes your ethnicity?

Hispanic or Latino

Not Hispanic or Latino

Don’t Know

Did Not Ask

Refused to Answer

6.What best describes your race? (check all that apply)

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Don’t Know

Did Not Ask

Refused to Answer

7.Please indicate if you have engaged in the following behaviors in the last 3 months:

Yes / No
(a) Sex with a Female /  / 
(b) Sex with a Male /  / 
(c) Sex with a Transgender /  / 
(d) Exchanged sex for drugs or money /  / 
(e) Sex while high /  / 
(f) Sex with an injection drug user (IDU) /  / 

8.Have you had sexual intercourse (vaginal or anal sex) in the past 12 months?

Yes

No (skip to question 16 )

Did Not Ask (skip to question 16)

Refused to Answer (skip to question16 )

9.How many sex partners have you had in the past 12 months? (total number) _____

Does Not Apply (skip to question 16)

Did Not Ask (skip to question16 )

Refused to Answer (skip to question 16)

10.Do you consider yourself exclusively partnered (i.e., involved in a sexual relationship with only one person)?

No

Yes, for less than 1 year

Yes, for more than 1 year

11.How many times have you had sex in the past 12 months?(Total number) _____

12.How many times have you had unprotected sex(i.e., sex without a condom) in the past 3 months? (total number) _____

The next set of statements involves your opinion about how your friends behave. Even if you are not completely sure, please answer each question with your best guess or “hunch.”

13.My friends always use condoms during intercourse.

Strongly Disagree / Disagree / Agree / Strongly Agree

14.Safer sex is completely accepted by my friends.

Strongly Disagree / Disagree / Agree / Strongly Agree

15.My friends are likely to have unsafe sex after drinking alcohol.

Strongly Disagree / Disagree / Agree / Strongly Agree

16.In the past 3 months, how many times have you talked to a friend or an acquaintance and told that person about the importance of staying sexually safe?______times(s)

17.Have you been tested for HIV?

No, I have not been tested.(Skip to question 22)

Yes, I was told that my result was negative.

Yes, I was told that my result was positive.

Yes, I but I never returned to learn the result.

18.When did you last test negative for HIV? ____ / ____ / (month/year)

Don’t Know

Did Not Ask

Refused to Answer

19.Have you injected drugs in the past 3 months?

Yes

No (Skip question 24)

Don’t Know

Did Not Ask

Refused to Answer

20.What substances did you inject? (check all that apply)

Heroin alone

Cocaine alone

Heroin and cocaine together

Crack

Amphetamines, speed, crystal meth, ice

Other narcotic drugs

Hormones

Steroids

Silicone

Botox

Other medical substance

Other (specify: ______)

This is the end of the survey.

Please flip through the pages and make sure you have answered every question.

THANKS FOR GIVING US SOME OF YOUR TIME-

WE APPRECIATE IT!

Evaluation Field Guide—September 20081