Lets Get Started...

Please write in here the country you live in

(A) How old are you

(B) What is your occupation/with what skills have you been trained?
(C) Are you currently working?
.... YES NO

(D) What ethnic or cultural background do you identify with?
..... AFRO CARIBBEAN INDO CARIBBEAN WHITE ASIAN MIXED RACE OTHER

(E) What town do you live in now?

Definitions
*Sexual intercourse involves penetration
e.g. vaginal, anal and does NOT include ORAL sex
**Drugs do not include alcohol

(1) If a member of your family became sick with AIDS, would you be willing
..... to care for him or her in your household?
.... YES NO DON'T KNOW

(2) If a teacher has the AIDS virus but is not sick, should he or she be allowed
......to continue teaching in school?
.... YES NO DON'T KNOW

(3) If you knew that a shopkeeper or food seller had the AIDS virus,
..... would you buy vegetables from them?
.... YES NO DON'T

(4) Can people protect themselves from HIV by not having anal sex?
.... YES NO DON'T KNOW

(5) Can people protect themselves from HIV
..... by using a condom correctly every time they have anal sex?
.... YES NO DON'T KNOW

(6) Have you ever had any female sex partners?
.... YES NO (If NO Skip to question #12)

(7) At what age did you first have sexual intercourse with a female?
......Write age in here:

(8) Think of the first time you had sex (penetration) with a female partner,
..... how old was your partner? Age

(9) Think of the first time you had sex (penetration) with a female partner,
......did you want to or were you forced? WANTED TO WAS FORCED

(10) Have you had sexual intercourse with any females in the past 12 months?
..... YES NO (If NO Skip to queston #12)

(11) How many female partners have you had sexual intercourse
....... with in the past 12 months? Write number:

(12) At what age did you first have sexual intercourse with a male?
...... Write age in here:

(13) Think of the first time you had sex (penetration) with a male partner,
....... how old was your partner? Age:

(14) Think of the first time you had sex (penetration) with a male partner,
....... did you want to or were you forced?
...... WANTED TO WAS FORCED

(15) How many men have you had anal intercourse with in the past 12 months?

(16) Of all these male partners in the past 12 months, how many were partners
...... who you paid to have sex with you or who paid you to have sex with them?
...... # I PAID FOR SEX # PAID ME TO HAVE SEX WITH THEM
...... (If the answer is NO to all of question 16, skip to # 18)

(17) The last time you had sex with a partner, was a condom used?
...... YES NO

(18) Of all these male partners in the past 12 months, how many were
...... non commercial partners (people who you DID NOT pay to have sex with you
...... or who DID NOT pay you to have sex with them?
...... (If NO for both, skip to # 18) #

(19) The last time you had sex with a NON-COMMERCIAL partner,
....... was a condom used? YES NO DON'T REMEMBER

(20) How often did you and all your partners use condoms in the last 30 days?
.... . EVERY TIME ALMOST EVERYTIME SOMETIME
.... . NEVER NO PARTNERS IN THE LAST 30 DAYS

(21) During the last 12 months, did any of your sexual partners force you
....... to have sex with them even though you did not want to have sex
....... (that is, you were unwilling to have sex)? YES NO

(22) Do you have a steady/regular partner? YES NO ( If NO Skip to #26 )

(23) Is this steady/regular partner male or female? MALE FEMALE

(24) Do you use condoms with your steady/regular partner?
..... YES NO ( If NO Skip to #26 )

(25) If you use condoms with your regular partner, how often?
..... EVERYTIME ALMOST EVERYTIME SOMETIME
..... NEVER NO PARTNER IN THE LAST 30 DAYS

(26) Do you use lubricants when you have sex?
..... EVERYTIME ALMOST EVERYTIME SOMETIME NEVER

(26a) Write type of lube you use:

(27) Some people used different types of drugs. Which of the following,
....... if any, have you used in the last 12 months?
...... MARIJUANA COCANE/CRACK AMPHETAMINESC (Speed Ice)
...... HALLUCINOGENUS - LSD ASCID, PCP DUST, HEROIN NO DRUGS USED
............ OTHER SPECIFY

(28) Have you ever given or received drugs (not alcohol) in exchange for having sex?
..... Yes, Given drugs to someone Yes, Received drugs from someone
..... Yes, Given and received drugs NO

(29) How often do you use drugs (not alcohol) and have sex at the same time?
..... EVERYTIME ALMOST EVERYTIME SOMETIME NEVER

(30) How often do you use alcohol and have sex at the same time?
...... EVERYTIME ALMOST EVERYTIME SOMETIME NEVER

(31) Have you ever been tested for HIV?
.... . YES NO ( Skip to #36 ) NOT SHURE ( Skip to #36 )

(32 ) How many times have you been tested for HIV? That you know of

(33) Do you know what the results are? YES NO DON'T KNOW

(34) If you feel comfortable enough to respond, please let us know what
.......your status was, the last time you got tested.
..... HIV POSITIVE HIV NEGATIVE RESULTS WERE UNCLEAR

(35) Why did you get tested for HIV?
..... Had sex with someone who I wasn't sure about
..... Because of a new partner
..... had symptoms
,,,,, just wanted to know
..... Other Specify

(36) (Answer the following question only if you have never been tested.)
......... Why have you not been tested for HIV?
..... Scared to find out results
..... I don't think I have HIV
..... I have a stable partner
,,,,, Just haven't gotten around to getting tested
..... ..... Other Specify

(37) Do you know the HIV status of your partner? YES NO

(38) Do you have a doctor or do you go to a clinic that you are comfortable with?
..... YES NO

(39) Do you have any friends or close acquaintances who have HIV/AIDS
...... or who have died from AIDS?
..... Yes I have friends living with HIV/AIDS
..... Yes I have friends who have died of AIDS .....
..... No, don't have any
..... Family who has AIDS
..... Family who has died of AIDS

(40) Where do you normally get your information about HIV? (Tick all that apply)
...... FRIENDS & FAMILY TV/ RADIO CLINIC / DOCTOR
....... .... OTHER

(41) What kind of prevention and support activities/programs
...... have you attended in the past? (Tick all that apply
..... Workshops/seminars
..... Chat room - internet
..... Counselling or chat room with physical site
,,,,, Workplace interventions
........ ..

(42) Please rank in order of preference from 1- 4
..... Workshops
..... Ongoing support groups
..... TV
,,,,, Radio
........... Other

(43) Where would you prefer to be reached with prevention
...... and support activities/programs?
...... Please rank in order of your preference from 1-4.
..... At Work
..... Small Group Intervention
..... Chatroom
,,,,, Location for General Population
......Other (Specify)


We would need some way of contacting you shoud you win.
please supply email & phone contact below.
email: .Phone Contact: .
........................................................................
.........