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* 1. Today's Date

Date

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* 2. Last five digits of your telephone number

I. Please indicate whether the following statements are true or false.

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* 3. Having unprotected sexual intercourse and sharing needles without properly cleaning equipment are the main modes of HIV transmission.

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* 4. HIV is spread through the air, by skin to skin contact, by insects and through saliva.

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* 5. You can tell whether someone has HIV by looking at him or her.

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* 6. I am safe if I clean up after I have unprotected intercourse (anal or vaginal).

II. Please indicate whether a person can become infected with HIV through the following modes of transmission.

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* 7. Sharing kitchen and bath facilities

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* 8. Sharing injection drug use needles

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* 9. Coughing, sneezing, or kissing

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* 10. Having anal or vaginal sex and pulling out before cumming

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* 11. Sharing a bed

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* 12. Using the same swimming pool

III. Please indicate whether the following behaviors are very risky, are risky, or have little or no risk

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* 13. Anal sex without a condom

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* 14. Oral sex without a condom

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* 15. Sex with a latex condom and a water-based lubricant

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* 16. Sex without a condom and pulling out before cumming

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* 17. Mutual masturbation without penetration

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* 18. Sex with a sheepskin condom

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* 19. Rubbing, cuddling, and kissing

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* 20. Oral sex with a condom

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* 21. Toys (dildos) not shared with a partner

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* 22. Dry humping (body rubbing to orgasm)

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* 23. IV Please list three factors that contribute to HIV risk among black men who have sex with men.

V. Please indicate how strongly you agree or disagree with each of the following statements.

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* 24. HIV is affecting black men who have sex with men.

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* 25. I feel that I understand why HIV continues to spread.

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* 26. People continue to hold on to myths about HIV.

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* 27. Friends can influence a person to not use condoms regularly.

VI. Please indicate how strongly you agree or disagree with each of the following statements

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* 28. I have an important role to play in preventing the spread of HIV.

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* 29. I am committed to preventing HIV.

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* 30. I have a responsibility to take on a leadership role around HIV.

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* 31. I am confident that I promote safer sex among my friends and acquaintances.

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* 32. I intend to have safer sex conversations with my friends and acquaintances.

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* 33. I feel comfortable discussing condom use.

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* 34. I feel comfortable starting conversations about safer sex with friends and acquaintances.

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* 35. I feel prepared to start conversations about safer sex with friends and acquaintances.

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* 36. I feel equipped to tailor safer sex messages to my different friends and acquaintances.

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