HIV/AIDS and Sexual Health Survey

*
3. Race/Ethnicity:

Race/Ethnicity: African American/Black

Asian/Pacific Islander

Caucasion/White

Hispanic/Latino

Native American/Alaska Native

Other (please specify)

*
4. What is your relationship status?

What is your relationship status? Married/domestic partner

Married/domestic partner, with other sexual partners

Living together, not legally married

Separated

Divorced

Widowed

Single, never married

In a relationship, but not living together or married

Other (please specify)

5. What is the highest grade of school or year of college you have completed? (Check One)

What is the highest grade of school or year of college you have completed? (Check One) None

Elementary school (grades 1-8)

Some high school (grades 9-11)

Completed H.S./H.S. Graduate/GED

Some college, but no degree (Associate’s higher)

Associate’s degree

Undergraduate degree from a 4 year institution

Some post-graduate work

Graduate degree or higher

6. Which of the following best describes where you live right now? (CHECK ONE ONLY)

Which of the following best describes where you live right now? (CHECK ONE ONLY) Rent

Own

Live with friends or family without paying rent

Homeless

Weekly motels

Other (please specify)

*
7. What do you consider your sexual orientation?

What do you consider your sexual orientation? Straight/Heterosexual

Gay/Homosexual

Bisexual

Other (please specify)

*
8. During the past 12 months who were your sexual partners?

During the past 12 months who were your sexual partners? Men only

Women only

Both men and women

I have not had sex within the last 12 months

Do not know

Prefer not to answer

*
9. How many sexual partners (vaginal, oral, anal) have you had in the past 12 months?

How many sexual partners (vaginal, oral, anal) have you had in the past 12 months? None

2-4

5-7

8-10

11 or more

*
10. Have you done any of the following in the past 12 months? (CHECK ALL THAT APPLY)

Have you done any of the following in the past 12 months? (CHECK ALL THAT APPLY) Had unprotected oral

Had unprotected vaginal sex

Had unprotected anal sex

None of the above

*
11. How often have you used condoms in the past 12 months when you had sex? (vaginal, oral, anal)

How often have you used condoms in the past 12 months when you had sex? (vaginal, oral, anal) Never

Seldom

Sometimes

Usually

Always

*
12. What may prevent you from using condoms? (check all that apply)

What may prevent you from using condoms? (check all that apply) I always use condoms

I only have sex with one person who I do not believe has sex with anyone else (i.e. in a commited relationship)

The person(s) I have sex with refuse to use them

I can't afford condoms

Feel uncomfortable asking for/ Buying condoms

I forget to bring condoms

I am usually drunk/high

They don't feel as good

Other (please specify)

13. Have you injected drugs in the past 12 months ?

Have you injected drugs in the past 12 months ? Yes

14. If Yes to the question above, have you done any of the following in the past 12 months? (CHECK ALL THAT APPLY)

If Yes to the question above, have you done any of the following in the past 12 months? (CHECK ALL THAT APPLY) Shared needles/works without bleaching

Shared needles for tattoos/piercing with someone who I believe injects drugs

Shared a cooker, cotton, or rinse water

None of the above

*
15. Have you ever been tested for HIV? (even if you didn't get the results. If no skip to question 17)

Have you ever been tested for HIV? (even if you didn't get the results. If no skip to question 17) Yes

16. When was the last time you were tested for HIV?

When was the last time you were tested for HIV? Less than 3 months ago

4-6 months ago

7-12 months ago

More than 12 months ago

Never

*
17. If you haven't been tested for HIV, why? (check all that apply)

If you haven't been tested for HIV, why? (check all that apply) I have not been exposed to HIV

I was afraid of finding out I am HIV positive

I thought I was HIV negative

I did not know where to get tested in this area

I was worried my name would be reported to the government if I test positive

Other (please specify)

18. If you had a question about HIV/AIDS, where would you go for information?
CHECK ALL THAT APPLY)

If you had a question about HIV/AIDS, where would you go for information? CHECK ALL THAT APPLY) Internet

Teacher

Health department

Family

Friends

Church

Partner

Health care provider

Community agency

Other (please specify)

19. For the following statements, please mark how you agree or disagree with the statement

	Strongly Agree	Somewhat Agree	Somewhat Disagree	Strongly Disagree
Medical care can help a person live longer and stay healthier if he/she has HIV/AIDS	*For the following statements, please mark how you agree or disagree with the statement Medical care can help a person live longer and stay healthier if he/she has HIV/AIDS Strongly Agree	Medical care can help a person live longer and stay healthier if he/she has HIV/AIDS Somewhat Agree	Medical care can help a person live longer and stay healthier if he/she has HIV/AIDS Somewhat Disagree	Medical care can help a person live longer and stay healthier if he/she has HIV/AIDS Strongly Disagree
My sexual partners and/or needle sharing partners are genuinely concerned with whether I have had an HIV/AIDS test and what the results were	My sexual partners and/or needle sharing partners are genuinely concerned with whether I have had an HIV/AIDS test and what the results were Strongly Agree	My sexual partners and/or needle sharing partners are genuinely concerned with whether I have had an HIV/AIDS test and what the results were Somewhat Agree	My sexual partners and/or needle sharing partners are genuinely concerned with whether I have had an HIV/AIDS test and what the results were Somewhat Disagree	My sexual partners and/or needle sharing partners are genuinely concerned with whether I have had an HIV/AIDS test and what the results were Strongly Disagree
I see HIV/AIDS as a manageable/treatable disease and am not as concerned about getting it	I see HIV/AIDS as a manageable/treatable disease and am not as concerned about getting it Strongly Agree	I see HIV/AIDS as a manageable/treatable disease and am not as concerned about getting it Somewhat Agree	I see HIV/AIDS as a manageable/treatable disease and am not as concerned about getting it Somewhat Disagree	I see HIV/AIDS as a manageable/treatable disease and am not as concerned about getting it Strongly Disagree
Taking HIV/AIDS drugs decreases the chances that someone with HIV/AIDS will infect their partners	Taking HIV/AIDS drugs decreases the chances that someone with HIV/AIDS will infect their partners Strongly Agree	Taking HIV/AIDS drugs decreases the chances that someone with HIV/AIDS will infect their partners Somewhat Agree	Taking HIV/AIDS drugs decreases the chances that someone with HIV/AIDS will infect their partners Somewhat Disagree	Taking HIV/AIDS drugs decreases the chances that someone with HIV/AIDS will infect their partners Strongly Disagree
Oral sex without a condom is safe if there is no ejaculation (cum)	Oral sex without a condom is safe if there is no ejaculation (cum) Strongly Agree	Oral sex without a condom is safe if there is no ejaculation (cum) Somewhat Agree	Oral sex without a condom is safe if there is no ejaculation (cum) Somewhat Disagree	Oral sex without a condom is safe if there is no ejaculation (cum) Strongly Disagree
Anal sex without a condom is safe if there is no ejaculation (cum)	Anal sex without a condom is safe if there is no ejaculation (cum) Strongly Agree	Anal sex without a condom is safe if there is no ejaculation (cum) Somewhat Agree	Anal sex without a condom is safe if there is no ejaculation (cum) Somewhat Disagree	Anal sex without a condom is safe if there is no ejaculation (cum) Strongly Disagree
Sometimes I do not use condoms because they require too much effort	Sometimes I do not use condoms because they require too much effort Strongly Agree	Sometimes I do not use condoms because they require too much effort Somewhat Agree	Sometimes I do not use condoms because they require too much effort Somewhat Disagree	Sometimes I do not use condoms because they require too much effort Strongly Disagree
I feel that people who got infected with HIV/AIDS through sex or drug use got what they deserve	I feel that people who got infected with HIV/AIDS through sex or drug use got what they deserve Strongly Agree	I feel that people who got infected with HIV/AIDS through sex or drug use got what they deserve Somewhat Agree	I feel that people who got infected with HIV/AIDS through sex or drug use got what they deserve Somewhat Disagree	I feel that people who got infected with HIV/AIDS through sex or drug use got what they deserve Strongly Disagree
I feel comfortable being around someone with HIV/AIDS	I feel comfortable being around someone with HIV/AIDS Strongly Agree	I feel comfortable being around someone with HIV/AIDS Somewhat Agree	I feel comfortable being around someone with HIV/AIDS Somewhat Disagree	I feel comfortable being around someone with HIV/AIDS Strongly Disagree
I feel that there is enough messaging/education about HIV/AIDS in my community	I feel that there is enough messaging/education about HIV/AIDS in my community Strongly Agree	I feel that there is enough messaging/education about HIV/AIDS in my community Somewhat Agree	I feel that there is enough messaging/education about HIV/AIDS in my community Somewhat Disagree	I feel that there is enough messaging/education about HIV/AIDS in my community Strongly Disagree
I would date someone who is infected with HIV/AIDS	I would date someone who is infected with HIV/AIDS Strongly Agree	I would date someone who is infected with HIV/AIDS Somewhat Agree	I would date someone who is infected with HIV/AIDS Somewhat Disagree	I would date someone who is infected with HIV/AIDS Strongly Disagree
HIV/AIDS does not affect my life	HIV/AIDS does not affect my life Strongly Agree	HIV/AIDS does not affect my life Somewhat Agree	HIV/AIDS does not affect my life Somewhat Disagree	HIV/AIDS does not affect my life Strongly Disagree
I am not concerned about getting HIV/AIDS……	I am not concerned about getting HIV/AIDS…… Strongly Agree	I am not concerned about getting HIV/AIDS…… Somewhat Agree	I am not concerned about getting HIV/AIDS…… Somewhat Disagree	I am not concerned about getting HIV/AIDS…… Strongly Disagree
I know where to get an HIV/AIDS test…………	I know where to get an HIV/AIDS test………… Strongly Agree	I know where to get an HIV/AIDS test………… Somewhat Agree	I know where to get an HIV/AIDS test………… Somewhat Disagree	I know where to get an HIV/AIDS test………… Strongly Disagree

20. Thank you for you time! Please add any additional comments here.

Thank you for you time! Please add any additional comments here.

HIV/AIDS and Sexual Health Survey
Exit this survey >>

1. Northern Nevada Outreach Team

*
1. Gender

*
2. Age

*
3. Race/Ethnicity:

*
4. What is your relationship status?

5. What is the highest grade of school or year of college you have completed? (Check One)

6. Which of the following best describes where you live right now? (CHECK ONE ONLY)

*
7. What do you consider your sexual orientation?

*
8. During the past 12 months who were your sexual partners?

*
9. How many sexual partners (vaginal, oral, anal) have you had in the past 12 months?

*
10. Have you done any of the following in the past 12 months? (CHECK ALL THAT APPLY)

*
11. How often have you used condoms in the past 12 months when you had sex? (vaginal, oral, anal)

*
12. What may prevent you from using condoms? (check all that apply)

13. Have you injected drugs in the past 12 months ?

14. If Yes to the question above, have you done any of the following in the past 12 months? (CHECK ALL THAT APPLY)

*
15. Have you ever been tested for HIV? (even if you didn't get the results. If no skip to question 17)

16. When was the last time you were tested for HIV?

*
17. If you haven't been tested for HIV, why? (check all that apply)

18. If you had a question about HIV/AIDS, where would you go for information?
CHECK ALL THAT APPLY)

19. For the following statements, please mark how you agree or disagree with the statement

20. Thank you for you time! Please add any additional comments here.

HIV/AIDS and Sexual Health SurveyExit this survey >>

1. Northern Nevada Outreach Team

*1. Gender

*2. Age

*3. Race/Ethnicity:

*4. What is your relationship status?

5. What is the highest grade of school or year of college you have completed? (Check One)

6. Which of the following best describes where you live right now? (CHECK ONE ONLY)

*7. What do you consider your sexual orientation?

*8. During the past 12 months who were your sexual partners?

*9. How many sexual partners (vaginal, oral, anal) have you had in the past 12 months?

*10. Have you done any of the following in the past 12 months? (CHECK ALL THAT APPLY)

*11. How often have you used condoms in the past 12 months when you had sex? (vaginal, oral, anal)

*12. What may prevent you from using condoms? (check all that apply)

13. Have you injected drugs in the past 12 months ?

14. If Yes to the question above, have you done any of the following in the past 12 months? (CHECK ALL THAT APPLY)

*15. Have you ever been tested for HIV? (even if you didn't get the results. If no skip to question 17)

16. When was the last time you were tested for HIV?

*17. If you haven't been tested for HIV, why? (check all that apply)

18. If you had a question about HIV/AIDS, where would you go for information? CHECK ALL THAT APPLY)

19. For the following statements, please mark how you agree or disagree with the statement

20. Thank you for you time! Please add any additional comments here.

HIV/AIDS and Sexual Health Survey
Exit this survey >>

*
1. Gender

*
2. Age

*
3. Race/Ethnicity:

*
4. What is your relationship status?

*
7. What do you consider your sexual orientation?

*
8. During the past 12 months who were your sexual partners?

*
9. How many sexual partners (vaginal, oral, anal) have you had in the past 12 months?

*
10. Have you done any of the following in the past 12 months? (CHECK ALL THAT APPLY)

*
11. How often have you used condoms in the past 12 months when you had sex? (vaginal, oral, anal)

*
12. What may prevent you from using condoms? (check all that apply)

*
15. Have you ever been tested for HIV? (even if you didn't get the results. If no skip to question 17)

*
17. If you haven't been tested for HIV, why? (check all that apply)

18. If you had a question about HIV/AIDS, where would you go for information?
CHECK ALL THAT APPLY)