image
image


Thank you for completing this survey about HIV prevention needs in the Coachella valley.

Your input will help us to create and offer support to stop the transmission of HIV to our friends, families, and loved ones.

Be assured that your responses are completely confidential. We will not be taking your name or keeping any information with the responses that could be used to identify you. Please be as candid as you can.

You will be receiving a small gift in appreciation for your time. You may decline to answer any
Of the questions.

1. Participant information

initials:
email address:
date of birth: (mm/dd/yyyy)
residence county:
zip code:
homeless: Yes No

2. Demographics

1. gender & pregnancy:

male
female
pregnant female
transgender: male to female
transgender: female to male
other, specify:

2. race/ethnicity

African American (not Hispanic)
American indian/alaskan native
Asian/pacific islander
Hispanic/Latino
White (not Hispanic)
other, specify:

3. Sexual orientation

gay male
bisexual
heterosexual
lesbian
declined/refused

4. HIV status: (circle one only)

positive
negative
inconclusive
declined/refused
don't know

5. What language do you speak at home?

only Spanish
more Spanish than English
both languages equally
more English than Spanish
English only
other, specify:

Education

1. What is your highest grade completed?

did not finish grade school
finished grade school 
some high school 
finished high school
some college
finished college
some post graduate degree

Drug use history

1. in the last 12 months, have you used any of the following drugs?  (Yes, No, Decline/Refuse)
Alcohol: Yes No Decline/Refuse
Crack (rock): Yes No Decline/Refuse
Amphetamine (speed. Crank, crystal, tina): Yes No Decline/Refuse
Cocaine (powder): Yes No Decline/Refuse
Nitrate/Nitrates (poppers, rush): Yes No Decline/Refuse
Heroin (junk, skag, smack, h.): Yes No Decline/Refuse
Ecstasy (MDMA, adam, E,a X): Yes No Decline/Refuse
GHB (liquid ecstasy, G): Yes No Decline/Refuse
Ketamine (special K, vitamin K, K): Yes No Decline/Refuse
Viagra: Yes No Decline/Refuse

3. Risk attitude

For each statement select if you strongly agree, agree, disagree, strongly disagree or if it does not apply to you.

For this question, “safe sex” means sex without exchange of blood or fluids, and with a condom.

Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not Apply

1. People I am intimate with only engage in safe sex.

2. I have trouble letting a sex partner know that I want.

3. I am able to avoid behavior that may put me at risk of HIV infection.

4. I feel capable of insisting on safe sex with a partner I have sex with regularly.

5. I feel uncomfortable buying condoms.

6. I find it difficult to have sex while drunk or high.

7. I know how to use a condom.

8. I am less concerned about putting myself at risk without a condom now that new anti-HIV drug combination treatments are available.

9. My friends encourage me not to have sex under the Influence of alcohol and/or other drugs.

10. Someone can talk me out of safer sex by persuading Me that they are HIV-negative.

11. Someone can talk me out of using a clean needle by persuading Me that they are HIV-negative.

12. I use the internet for potential sexual partners.

13. I use the internet for potential sexual partners.

4. Barriers

Below is a list of reasons that may prevent people from accessing information and service related to HIV/AIDS. To identify if this has been a barrier for YOU in the past 12 months, please respond to the below statements.

For each statement, circle ‘1’ if you strongly agree; ‘2’ if you agree; ‘3’ if you disagree; ‘4’ if you strongly disagree; ‘5’ if it does not apply to you.

Strongly AgreeAgreeDisagreeStrongly DisagreeDoes Not Apply

1. HIV/AIDS prevention programs are available to me.

2. I have knowledge of where to obtain the HIV Prevention service(s) I need

3. I have transportation to get to the place where the program is provided.

4. I was (or am) in denial that I was (or am) at risk for HIV infection

5. I can find prevention programs in the language that I speak

6. I have child care needs that prevent me from accessing  prevention services.

7. I have knowledge of who to ask for help.

8. I am satisfied with the ethnic sensitivity of the organization and/or person providing service to me.

9. I am satisfied with the sexual orientation sensitivity of the organization and/or person providing the prevention service.

10. I am satisfied with the gender sensitivity of the organization and/or person providing the prevention service.

11. I feel that other discrimination by the persons and/or organization providing the prevention service or info has kept me from accessing services.

12. I am satisfied with the experience or expertise of the person providing prevention services to me.

13. The amount of time I had to wait to receive prevention info or services has kept me away.

14. The organization providing programs adequately answered my questions.

Thank you for your input. Your views will help to make services in prevention and care available to our friends, family and neighbors affected by HIV who need them. 

Please ask about the incentive available for completing this form

Do you have any additional comments?


















image
image
 © Copyright 2008 Desert AIDS Project | Reproduction prohibited
Palm Springs gay mens health, gay health and men's sexual health crisis information. 		All Rights Reserved | PSGayMensHealth.com | Gay Health | Mens Sexual Health  


DISCLAIMER: Warning! 18 years or older only. This website contains adult information.


You are attempting to access a website that contains adult specific educational material of adults engaged in sexual activity with other adults. Minors are prohibited from entering this site. Only adults who are at least 18 years of age and who have the legal right to possess adult materials in the communities in which they reside may enter. If you are not at least 18 years of age (or are otherwise not permitted to access adult content), you MAY NOT enter this Website.

TERMS OF USE   |  By entering this website I agree that:

Bookmarking, direct linking or deep linking to a page on this website whereby this Disclaimer Warning are bypassed shall constitute an explicit acknowledgement that the person accessing the website via the bookmark, direct link or deep link is at least 18 years old and has read, accepted and agreed to these Terms of Use.

By clicking below,I indicate that I have read and agree to these terms.