Form Approved
OMB No. 0920-New
Expiration Date: XX/XX/XXXX
“Community-based Organization Outcome Monitoring Projects for CBO HIV Prevention Services Clients”
Category 2 Focus Group Questionnaire
Public reporting burden of this collection of information is estimated to average 1 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)
Category 2 Pre-Focus Group Questionnaire
Please tell me the month and year of your date of birth?
__ __/__ __ __ __ (MM/YYYY)
How old are you?
__ __ __
Are you: (Choose one)
Hispanic or Latino
Not Hispanic or Latino
Decline to answer
Don’t know
What is your race? (Choose all that apply)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Declined to answer
Don’t know
What was your sex at birth? (Choose only one.)
Male
Female
Declined to answer
Don’t know
Do you consider yourself to be male, female, or transgender? (Choose only one.)
Male
Female
Transgender (MTF)
Transgender (FTM)
Transgender (not specified)
Declined to answer
Don’t know
Do you think of yourself as:
Lesbian or gay
Straight, that is, not gay or lesbian
Bisexual
Something else
Declined to answer
Don’t know
Are you attracted to other males?
Yes
No
Declined to answer
Don’t know
In the past 2 years, that is, since [MM/YYYY], how many times have you been tested for HIV?
___ ___ ___
Declined to answer
Don’t know