Download:
pdf |
pdfForm Approved OMB No. 0990-XXXX
Exp.Date XX/XX/XX11
Prevention Education Post-Test Questionnaire for College Women
INSTRUCTIONS: Check the box next to your answer.
DATE: _____________________
ID#: _
INFORMATION ABOUT YOU
1. How old are you? _______(Specify in
years)
2. What is your classification in college?
Freshman
Sophomore
Junior
Senior
Other (Specify)______________
3. What is your relationship status?
Single
Married
Married but separated
Common Law
Common Law but separated
Partnered
Divorced
Widowed
Other (Specify)______________
____
4. Where do you currently live?
On campus dorm/student
housing
At home with parents/relatives
Off campus apartment with
roommates
Off campus with partner
Don’t have a stable living
arrangement
Other (Specify)______________
5. Do you have access to health care?
Yes
No
Don’t know
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0990-XXXX. The time required to complete this information collection is estimated
to average 20 minutes per respondent, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to:
U.S. Department of Health & Human Services
OS/OIRM/PRA
200 Independence Ave., S.W. Suite 531-H
Washington, D.C. 20201
Attention: PRA Reports Clearance Officer
Page 1 of 7
GEARS Inc.
8/26/08
Confidential Proprietary Information
KNOWLEDGE ABOUT HIV
For each statement, please circle “True” (T), “False” (F), or “I don’t know” (DK). If you do not know,
please do not guess; instead, please circle “DK”.
1. Coughing and sneezing DO NOT spread HIV.
T
F
DK
2. A person can get HIV by sharing a glass of water
with someone who has HIV.
T
F
DK
3. Pulling out the penis before a man
climaxes/cums keeps a woman from getting HIV
during sex.
T
F
DK
4. A woman can get HIV if she has anal sex with a
man.
T
F
DK
5. Showering, or washing one’s genitals/private
parts after sex keeps a person from getting HIV.
T
F
DK
6. All pregnant women infected with HIV will have
babies born with HIV.
T
F
DK
7. In general, people who have been infected with
HIV quickly show serious signs of being infected.
T
F
DK
8. There is a vaccine that can stop adults from
getting HIV.
T
F
DK
9. People are likely to get HIV by deep kissing or
putting their tongue in their partner’s mouth, if
their partner has HIV.
T
F
DK
10. A woman cannot get HIV if she has sex during her
period.
T
F
DK
11. There is a female condom that can help decrease
a woman’s chance of getting HIV.
T
F
DK
12. A natural skin condom works better against HIV
than does a latex condom.
T
F
DK
13. A person will NOT get HIV if she or he is taking
antibiotics.
T
F
DK
14. Having sex with more than one partner can
increase a person’s chance of being infected with
HIV.
T
F
DK
15. Taking a test for HIV one week after having sex
will tell a person if she or he has HIV.
T
F
DK
Page 2 of 7
GEARS Inc.
8/26/08
Confidential Proprietary Information
16. A person can get HIV by sitting in a hot tub or a
swimming pool with a person who has HIV.
T
F
DK
17. A person can get HIV from unprotected oral sex.
T
F
DK
18. Using Vaseline or baby oil with condoms lowers
the chance of getting HIV.
T
F
DK
19. People can contract the HIV virus through
tattooing or body piercing if sterile instruments
are not used.
T
F
DK
20. It is easier for a woman to get HIV than to give it.
T
F
DK
21. A woman can give HIV to her baby or a sexual
partner through breast milk.
T
F
DK
22. Taking an oral contraceptive or hormones
decreases your risk to get HIV.
T
F
DK
23. Having unprotected sex with a partner is like
having sex with all of their current and previous
partners.
T
F
DK
24. When I get a pap smear, I’m automatically tested
for STIs/STDs.
T
F
DK
25. Ethnic minority women have higher rates of HIV
and STIs/STDs than white women.
T
F
DK
26. Your HIV risk increases if you or your sexual
partner injects drugs.
T
F
DK
27. Douching decreases a woman’s risk for getting
HIV.
T
F
DK
28. Using alcohol or party drugs increases the risk for
getting HIV by impairing your judgement.
T
F
DK
Page 3 of 7
GEARS Inc.
8/26/08
Confidential Proprietary Information
1.
2.
3.
4.
5.
6.
7.
8.
9.
YOUR EXPERIENCES
Have you ever engaged in:
(Select all that apply)
Oral Sex
Vaginal Sex
Anal sex
I have never engaged in oral,
vaginal or anal sex.
How would you describe yourself?
(Select all that apply)
Straight/Heterosexual
Gay/Lesbian/Homosexual
Bisexual
Transgendered
Unsure
Other (Specify)______________
When you have sex, you have sex with:
(Select one)
Men
Women
Both
Neither - I have never had oral,
vaginal, or anal sex.
Have you had sex in the past 30 days?
Yes
No
In the past 30 days, how many times did
you give oral sex? ______ (Please give
number)
In the past 30 days, how many times did
you give oral sex without a latex
barrier? _______ (Please give number)
In the past 30 days, how many times did
you receive oral sex? _______ (Please
give number)
In the past 30 days, how many times did
you receive oral sex without a latex
barrier? ________ (Please give number)
In the past 30 days, how many times did
you have vaginal sex? ______ (Please
give number)
10. In the past 30 days, how many times did
you have vaginal sex without a
condom? _______ (Please give number)
11. In the past 30 days, how many times did
you have anal sex? _______ (Please
give number)
12. In the past 30 days, how many times did
you have anal sex without a condom?
________ (Please give number)
13. In the past 30 days, did you have sex
without a condom with someone who is
not your spouse or primary partner?
Yes
No
14. In the past 30 days, did you have sex
without a condom with someone who
shoots drugs with needles? (Select one)
Yes
No
Don’t know
15. In the past 30 days, did you have sex
without a condom in exchange for
drugs?
Yes
No
16. In the past 30 days, did you have sex
without a condom because you feared
losing a financial benefit (gas, grocery,
rent, clothes, etc.)?
Yes
No
17. In the past 30 days, did you have sex
without a condom while you or your
partner were “high” on drugs or
alcohol? (Select one)
Yes
No
Don’t know
18. In the past 30 days, how many different
sexual partners have you had?
________ (Please give number)
Page 4 of 7
GEARS Inc.
8/26/08
Confidential Proprietary Information
19. In the past 30 days, with how many
different people have you engaged with
in the following acts?
Giving oral sex_______
Receiving Oral sex______
Vaginal sex_______
Anal sex_________
20. In the past 30 days, have you ever had
sex without a condom because you
feared losing a partner?
Yes
No
21. In the past 30 days, have you ever felt
forced or intimidated into having sex
without a condom?
Yes
No
22. What is the age of your current or last
partner? _________
23. Have you ever been tested for a
sexually transmitted infection/disease
(STI/STD)? (Select one)
Yes
No
Do not wish to answer
24. If yes, when were you last tested?
_______________(mm/yy)
25. Have you ever been treated for a
sexually transmitted infection/disease
(STI/STD)? (Select one)
Yes
No
Do not wish to answer
26. Have you ever been tested for HIV?
(Select one)
Yes
No
Do not wish to answer
27. If yes, when were you last tested?
___________(mm/yy)
28. Have you ever been told that you have
HIV? (Select one)
Yes
No
Do not wish to answer
29. Have you had a pap smear in the last 12
months?
Yes
No
30. Have you ever spent time in a detention
center, jail or prison?
Yes
No
31. Have any of your sexual partners been
in a detention center, jail or prison?
(Select one)
Yes
No
I don’t know
32. Have you ever felt that alcohol or drugs
were a problem for you?
Yes
No
33. Are you currently in a monogamous
relationship?
Yes
No
34. Do you receive financial assistance from
your sexual partner(s)?
Yes
No
35. Are you currently using contraceptives
to keep from getting pregnant (i.e. birth
control pills, diaphragms, etc.)?
(Select one)
Yes
No
Not currently sexually active
36. Are you currently trying to get
pregnant?
Yes
No
Page 5 of 7
GEARS Inc.
8/26/08
Confidential Proprietary Information
37. Do you have any children?
Yes
No
38. If yes, how many?
I have ____ children.
39. Have you ever been forced to have sex
when you didn’t want to?
Yes
No
40. Has your current partner ever physically
hurt you?
Yes
No
41. Are you worried about getting
HIV/AIDS?
Not at all
A little
Somewhat
A lot
42. Are you worried about getting a
sexually transmitted infection/disease
(STI/STD)?
Yes
No
43. Are you worried that you may already
have been exposed to HIV/AIDS?
Yes
No
44. Would you use a female condom if your
male sex partner didn’t want to use a
male condom?
Yes
No
45. Have you ever had unprotected sex
with a new partner because you were
upset with, just broke up with, or been
dumped by your current partner?
Yes
No
46. Have you ever had unprotected sex
with a new partner because you were
upset about school or your grades?
Yes
No
47. Have you ever dated someone who you
knew had HIV/AIDS?
Yes
No
48. Have you ever had unprotected oral,
anal, or vaginal sex with someone who
you knew was HIV positive?
Yes
No
49. If I were to suggest using a condom to a
partner, I would feel afraid that he or
she would reject me.
Strongly disagree
Disagree
Not sure
Agree
Strongly agree
50. If I were unsure of my partner’s feelings
about using condoms, I would not
suggest using one.
Strongly disagree
Disagree
Not sure
Agree
Strongly agree
51. I would feel comfortable discussing
condom use with a potential sexual
partner.
Strongly disagree
Disagree
Not sure
Agree
Strongly agree
Page 6 of 7
GEARS Inc.
8/26/08
Confidential Proprietary Information
52. How comfortable did you feel answering these questions honestly?
Very uncomfortable
Somewhat uncomfortable
Somewhat comfortable
Very comfortable
53. Tell us about your experience with the program. Circle the rating that best describes how you feel.
How helpful was the
HIV/AIDS information you
received?
Not
Helpful
Somewhat
Helpful
Helpful
Very
Helpful
How satisfied are you with
the information that you
have received?
Not
Satisfied
Somewhat
Satisfied
Satisfied
Very
Satisfied
How would you rate the
project personnel’s ability
to make the HIV/AIDS
information easy to
understand?
Poor
Fair
Good
Excellent
How would you rate the
project personnel’s
knowledge of HIV/AIDS?
Poor
Fair
Good
Excellent
How would you rate the
women-specific HIV/AIDS
information you received?
Poor
Fair
Good
Excellent
Overall, how do you rate
this HIV/AIDS education
program?
Poor
Fair
Good
Excellent
Page 7 of 7
GEARS Inc.
8/26/08
Confidential Proprietary Information
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |