SPNS COOPERATIVE AGREEMENT EVALUATION

MODULE 31: SEXUAL BEHAVIORS FORM INSTRUCTIONS

Citation: Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1996). Module 31: Sexual Behaviors Form. Available: www.TheMeasurementGroup.com. Culver City, California: The Measurement Group.

Answer questions by either filling in a circle, or writing a number or letter in a square box. If the answer goes in a square box, you must use a CAPITAL LETTER or number that does not touch the side of the box. Print only one letter or number in each box. If the letters or numbers that you print touch the sides of the boxes, or if you do not clearly print the information, the computer will "kick out" the form and we will need to return it to you to be completed correctly. If the question asks the answer to be filled in a circle, make sure that the circle is completely darkened. Only darken one circle for each question unless the instructions specifically tell you to darken as many as apply for that question.

Specific Parts of the Module 31: Sexual Behaviors Form

Please note that Module 31 is two pages long. Both pages should be completed.

ID Letters/ID Numbers. These boxes are provided for entering the unique identifier your site is using to track client information. The four boxes on the left are to be used for letters, while the ten boxes on the right are reserved for numbers. You may use letters, numbers, or a combination of letters and numbers, for identification purposes. If you use a combination of letters and numbers, however, please use the letters first in your alphanumeric sequence (for example, if your unique identifier is MD-1479, the letters "M" and "D" would be entered in the first two of the four boxes reserved for letters and the numbers "1", "4", "7", and "9" would be entered into the first four of the ten boxes reserved for numbers). If you are unsure about a client’s unique identifier, check with your project director.

Site. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form. Site codes are 3 letters.

Sub-Provider. This field may be used to designate specific sites or providers within your project. If appropriate, enter the code for the service provider agency doing the activity. Provider codes can be up to 3 letters.

Date. Enter the numbers representing today's date (the date of the activity) in these boxes. Enter the month as a number from 01 to 12 for January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "95" for 1995). Make sure that if a month or day is less than 10, you place a "0" before the number.

Staff Code. Each staff member should be assigned a unique number code (up to 3 digits). Make sure than each new staff member has a unique code. Do not reassign any staff codes that have been previously assigned. Enter the 3-digit code for the person who provided the services. If the staff code is less than 3 digits, place "0"s before the number. For example, 3 is "003."

Client Gender. Darken the circle next to the response that indicates the person's gender.

Have you had vaginal sex…(Interviewer explain what this means)

In the last month? If the client responds "No,", "Don’t Know,’ or refuses to answer darken the appropriate circle and go to question 2. If the client responds "Yes," go to question 1b

About how many times has this happened in the last month? In the boxes provided enter the number of times that the client has had vaginal sex in the last month. Right justify the number by placing "0s" to the left of it. For example, if the client has had vaginal sex 7 times in the last month, enter "007." If the client does not know how many times she/he has had vaginal sex in the last month, enter "777." If she/he refuses to tell you how many times, enter "888." Then go to question 1c.

About how many people have you done this with in the last month? In the boxes provided enter the number of people that the client has had vaginal sex with in the last month. Right justify the number by placing "0s" to the left of it. For example, if the client has had vaginal sex 3 people in the last month, enter "003." If the client does not know how many people she/he has had vaginal sex with in the last month, enter "777." If she/he refuses to tell you how many, enter "888." Then go to question 1d.

Have you done this without out a condom or other latex protection in the last month? If the client has had vaginal sex without a condom, darken the circle next to "Yes." If the client has not had vaginal sex without a condom, darken the circle next to "No." If she/he does not know, darken the circle next to "Don’t Know." If she/he refuses to answer, darken the circle next to "Refused." Then go to question 2.

Have you performed oral sex on a male partner…?(Interviewer explain what this means)

In the last month? If the client responds "No,", "Don’t Know,’ or refuses to answer darken the appropriate circle and go to question 3. If the client responds "Yes," go to question 2b

About how many times has this happened in the last month? In the boxes provided enter the number of times that the client has performed oral sex on a male partner in the last month. Right justify the number by placing "0s" to the left of it. For example, if the client has performed oral sex on a male partner 7 times in the last month, enter "007." If the client does not know how many times she/he has performed oral sex on a male partner in the last month, enter "777." If she/he refuses to tell you how many times, enter "888." Then go to question 2c.

About how many people have you done this with in the last month? In the boxes provided enter the number of men that the client has performed oral sex on in the last month. Right justify the number by placing "0s" to the left of it. For example, if the client has performed oral sex on 3 men in the last month, enter "003." If the client does not know how many men she/he has performed oral sex on in the last month, enter "777." If she/he refuses to tell you how many, enter "888." Then go to question 2d.

Have you done this is without out a condom or other latex protection in the last month? If the client has performed oral sex on a male partner without a condom, darken the circle next to "Yes." If the client has not performed oral sex on a male partner without a condom, darken the circle next to "No." If she/he does not know, darken the circle next to "Don’t Know." If she/he refuses to answer, darken the circle next to "Refused." Then go to question 3.

Have you performed oral sex on a female partner…?(Interviewer explain what this means)

In the last month? If the client responds "No,", "Don’t Know,’ or refuses to answer darken the appropriate circle and go to question 4. If the client responds "Yes," go to question 3b.

About how many times has this happened in the last month? In the boxes provided enter the number of times that the client has performed oral sex on a female partner in the last month. Right justify the number by placing "0s" to the left of it. For example, if the client has performed oral sex on a female partner 7 times in the last month, enter "007." If the client does not know how many times she/he has performed oral sex on a female partner in the last month, enter "777." If she/he refuses to tell you how many times, enter "888." Then go to question 3c.

About how many people have you done this with in the last month? In the boxes provided enter the number of women that the client has performed oral sex on in the last month. Right justify the number by placing "0s" to the left of it. For example, if the client has performed oral sex on 3 women in the last month, enter "003." If the client does not know how many women she/he has performed oral sex on in the last month, enter "777." If she/he refuses to tell you how many, enter "888." Then go to question 3d.

Have you done this is without out a condom or other latex protection in the last month? If the client has performed oral sex on a female partner without a condom, darken the circle next to "Yes." If the client has not performed oral sex on a female partner without a condom, darken the circle next to "No." If she/he does not know, darken the circle next to "Don’t Know." If she/he refuses to answer, darken the circle next to "Refused." Then go to question 4.

Has a male partner performed oral sex on you…?(Interviewer explain what this means)

In the last month? If the client responds "No,", "Don’t Know,’ or refuses to answer darken the appropriate circle and go to question 5. If the client responds "Yes," go to question 4b.

About how many times has this happened in the last month? In the boxes provided enter the number of times that the client has had a male partner perform oral sex on her/him in the last month. Right justify the number by placing "0s" to the left of it. For example, if the client has had a male partner perform oral sex on her/him 7 times in the last month, enter "007." If the client does not know how many times she/he has had a male partner perform oral sex on her/him in the last month, enter "777." If she/he refuses to tell you how many times, enter "888." Then go to question 4c.

About how many people have you done this with in the last month? In the boxes provided enter the number of men that performed oral sex on the client in the last month. Right justify the number by placing "0s" to the left of it. For example, if the 3 men performed oral sex on the client in the last month, enter "003." If the client does not know, enter "777." If she/he refuses to tell you how many, enter "888." Then go to question 4d.

Have you done this is without out a condom or other latex protection in the last month? If the client has had a male partner perform oral sex on her/him without a condom, darken the circle next to "Yes." If the client has not had a male partner perform oral sex on her/him without a condom, darken the circle next to "No." If she/he does not know, darken the circle next to "Don’t Know." If she/he refuses to answer, darken the circle next to "Refused." Then go to question 5.

Has a female partner performed oral sex on you…?(Interviewer explain what this means)

In the last month? If the client responds "No,", "Don’t Know,’ or refuses to answer darken the appropriate circle and go to question 6 (Module 31,page 2). If the client responds "Yes," go to question 5b.

About how many times has this happened in the last month? In the boxes provided enter the number of times that the client has had a female partner perform oral sex on her/him in the last month. Right justify the number by placing "0s" to the left of it. For example, if the client has had a female partner perform oral sex on her/him 7 times in the last month, enter "007." If the client does not know how many times she/he has had a female partner perform oral sex on her/him in the last month, enter "777." If she/he refuses to tell you how many times, enter "888." Then go to question 5c.

About how many people have you done this with in the last month? In the boxes provided enter the number of women that performed oral sex on the client in the last month. Right justify the number by placing "0s" to the left of it. For example, if the 3 women performed oral sex on the client in the last month, enter "003." If the client does not know, enter "777." If she/he refuses to tell you how many, enter "888." Then go to question 5d.

Have you done this is without out a condom or other latex protection in the last month? If the client has had a female partner perform oral sex on her/him without a condom, darken the circle next to "Yes." If the client has not had a female partner perform oral sex on her/him without a condom, darken the circle next to "No." If she/he does not know, darken the circle next to "Don’t Know." If she/he refuses to answer, darken the circle next to "Refused."

 

Specific Parts of Module 31 (Page 2): Sexual Behaviors Form

Please note that Module 31 is two pages long. Before beginning Page 2 of Module 31, Page 1 should be completed.

Please have site staff fill in the following information on the Module 31 (page 2) form:

ID Letters/ID Numbers, Site, Sub-Provider, and Date

Has a partner performed anal sex on you…?(Interviewer explain what this means)

In the last month? If the client responds "No,", "Don’t Know,’ or refuses to answer darken the appropriate circle and go to question 7. If the client responds "Yes," go to question 6b

About how many times has this happened in the last month? In the boxes provided enter the number of times that the client has had anal sex performed on her/him in the last month. Right justify the number by placing "0s" to the left of it. For example, if 7 times in the last month, enter "007." If the client does not know how many times in the last month, enter "777." If she/he refuses to tell you how many times, enter "888." Then go to question 6c.

About how many people have you done this with in the last month? In the boxes provided enter the number of people that performed anal sex on the client in the last month. Right justify the number by placing "0s" to the left of it. For example, if 3 people in the last month, enter "003." If the client does not know, enter "777." If she/he refuses to tell you how many, enter "888." Then go to question 6d.

Have you done this is without out a condom or other latex protection in the last month? If the client has had anal sex performed on her/him without a condom, darken the circle next to "Yes." If the client has not anal sex performed on her/him without a condom, darken the circle next to "No." If she/he does not know, darken the circle next to "Don’t Know." If she/he refuses to answer, darken the circle next to "Refused." Then go to question 7.

Have you had sex with someone you think is a drug injector or shooter…?(Interviewer explain what this means)

In the last month? If the client responds "No,", "Don’t Know,’ or refuses to answer darken the appropriate circle and go to question 8. If the client responds "Yes," go to question 7b.

About how many times has this happened in the last month? In the boxes provided enter the number of times that the client has had sex with someone who is a drug injector or shooter in the last month. Right justify the number by placing "0s" to the left of it. For example, if the client has had sex with someone who is a drug injector or shooter 7 times in the last month, enter "007." If the client does not know how many times, enter "777." If she/he refuses to tell you how many times, enter "888." Then go to question 7c.

About how many people have you done this with in the last month? In the boxes provided enter the number of people that who may be drug injectors or shooters. Right justify the number by placing "0s" to the left of it. For example, if 3 people, enter "003." If the client does not know, enter "777." If she/he refuses to tell you how many, enter "888." Then go to question 7d.

Have you done this is without out a condom or other latex protection in the last month? If the client has had sex with a drug injector or shooter without a condom, darken the circle next to "Yes." If the client has not had sex with a drug injector or shooter without a condom, darken the circle next to "No." If she/he does not know, darken the circle next to "Don’t Know." If she/he refuses to answer, darken the circle next to "Refused." Then go to question 8.

MALES ONLY: Have you performed anal sex on a male partner…?(Interviewer explain what this means)

In the last month? If the client responds "No,", "Don’t Know,’ or refuses to answer darken the appropriate circle and go to question 9. If the client responds "Yes," go to question 8b.

About how many times has this happened in the last month? In the boxes provided enter the number of times that the client performed anal sex on a male partner in the last month. Right justify the number by placing "0s" to the left of it. For example, if the client has performed anal sex on a male partner 7 times in the last month, enter "007." If the client does not know how many times, enter "777." If he refuses to tell you how many times, enter "888." Then go to question 8c.

About how many people have you done this with in the last month? In the boxes provided enter the number of men that the client performed anal sex on in the last month. Right justify the number by placing "0s" to the left of it. For example, if the 3 men in the last month, enter "003." If the client does not know, enter "777." If he refuses to tell you how many, enter "888." Then go to question 8d.

Have you done this is without out a condom or other latex protection in the last month? If the client has performed anal sex on a male partner in the last month without a condom, darken the circle next to "Yes." If the client has not performed anal sex on a male partner in the last month without a condom, darken the circle next to "No." If he does not know, darken the circle next to "Don’t Know." If he refuses to answer, darken the circle next to "Refused." Then go to question 9.

MALES ONLY: Have you performed anal sex on a female partner…(Interviewer explain what this means)

In the last month? If the client responds "No,", "Don’t Know,’ or refuses to answer darken the appropriate circle and go to question 10. If the client responds "Yes," go to question 9b.

About how many times has this happened in the last month? In the boxes provided enter the number of times that the client performed anal sex on a female partner in the last month. Right justify the number by placing "0s" to the left of it. For example, if the client has performed anal sex on a female partner 7 times in the last month, enter "007." If the client does not know how many times, enter "777." If he refuses to tell you how many times, enter "888." Then go to question 8c.

About how many people have you done this with in the last month? In the boxes provided enter the number of women that the client performed anal sex on in the last month. Right justify the number by placing "0s" to the left of it. For example, if 3 women in the last month, enter "003." If the client does not know, enter "777." If he refuses to tell you how many, enter "888." Then go to question 8d.

Have you done this is without out a condom or other latex protection in the last month? If the client has performed anal sex on a female partner in the last month without a condom, darken the circle next to "Yes." If the client has not performed anal sex on a female partner in the last month without a condom, darken the circle next to "No." If he does not know, darken the circle next to "Don’t Know." If he refuses to answer, darken the circle next to "Refused." Then go to question 10.

(Ask of Male and Females) Do you have someone you consider your main sexual partner…?

How long have you been together? If the client responds "No,", "Don’t Know,’ or refuses to answer darken the appropriate circle and go to question 11. If the client responds "Yes", enter the number of years, months, or days as a two digit number that the client has been with his/her partner. For example, if the client has been with his/her partner for 3 years, you would enter "03" in the boxes marked "Years."

How often do you use condoms, dental dams, or other latex protection (such as latex glove or saran wrap when you have sex with you main sexual partner)? Read the list of choices to the client and darken the circle next to his/her choice.

A lot of people have found that they needed to exchange sex to get food, a place to stay (shelter), money, or drugs. Have you done that?

In the last 6 months? If the client has exchanged sex for the reasons listed above in the last month darken the circle next to "Yes" and go to question 11b. Otherwise darken the appropriate circle and end the interview.

In the last 30 days? If the client has exchanged sex for the reasons listed above in the last 30 days darken the circle next to "Yes" and go to question 11b. Otherwise darken the appropriate circle and end the interview.

In the last 7 days? If the client has exchanged sex for the reasons listed above in the last 7 days darken the circle next to "Yes" and end the interview. Otherwise darken the appropriate circle and end the interview.