1. What is your date of birth? Month Day Year

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1 Participant ID # Today's Date 1. What is your date of birth? Month Day Year 2. How would you describe your race / ethnicity? African American / Black European American / White Hispanic Asian Native American / American Indian Multi-ethnicity / bi-racial Other 3. What kind of school are you going to? Not in school High School Working on a GED Trade/Vocational College Other 4. Do you plan to finish high school or get a GED? Finish high school Get GED No Have finished high school or GED already 5. How old were you when you had sex for the first time? 6. Do you think that you are infertile (you are unable to get pregnant)? Yes No Don t know 7. In the past 3 months, which of the following problems have you ever been told by a doctor or nurse that you had? Circle Yes or No for each one: Yes No Crabs Yes No Chlamydia Yes No Genital herpes Yes No Syphilis, syph Yes No GC, gonorrhea, clap Yes No Genital Warts, HPV, human papilloma virus Yes No Hepatitis Yes No Trichomoniasis, trich Yes No AIDS, HIV Yes No None 8. During the past 3 months, have you had a pregnancy test? Yes, tested at a clinic or Dr. s office Yes, tested at home No 9. During the past 3 months, have you had a positive pregnancy test or been pregnant? Yes No Page 1

2 10. During the past 30 days, how many times did you have sex? Times 11. During the past 3 months, with how many people did you have sex? 12. The last time you had sex, was it against your will in any way? Yes No 13. What forms of birth control did you use the last time you had sex? Circle Yes or No for each one: Yes No None Yes No Birth control pills Yes No Condoms Yes No Pulling out, withdrawal Yes No Spermicide such as VCF, foam or Conceptrol Yes No Birth control shot, Depo Provera Yes No Norplant Yes No Morning after pills, emergency contraception Yes No Rhythm Yes No Diaphragm Yes No Other 14. The last time you used a condom, where did you get it? Never used a condom Guy that I had sex with had it From a friend Brother or sister Mother or father Other relative School clinic Family planning clinic Other clinic, private doctor, nurse practitioner Drug store Somewhere else - where? 15. During the past 3 months, how often did you use condoms when having sex? Every time, with every partner Almost every time More than half the time About half the time Less than half the time Never 16. Over the past 3 months, which of the following have happened to you? Circle Yes or No for each one (If yes, how many times?) a. Condom broke or ripped Yes ( number of times) No b. Condom fell off Yes ( number of times) No c. Condom leaked Yes ( number of times) No Page 2

3 For this survey, we are interested in 8 sexually transmitted infections (STIs): HIV/AIDS, Chlamydia, Genital Herpes, Genital Warts, Gonorrhea, Hepatitis B, Syphilis, and Trichomonas. When the questions below ask about STIs, they are referring to these diseases. true don't know Circle 'T' for True or 'F' for False. If you don t know, circle '?' false T? F This question is an example. 1. T? F A common symptom of STIs in a man is discharge (drip) from his penis. 2. T? F A common symptom of STIs is burning with urination. 3. T? F A common symptom of STIs is a sore on the penis or vagina. 4. T? F A common symptom of STIs in a woman is discharge from her vagina that causes itching or burning. 5. T? F You can not have an STI if you feel perfectly fine. 6. T? F A woman who has an STI can get an infection in her uterus and tubes. 7. T? F A pregnant woman who has an STI can give it to her baby. 8. T? F There are medicines to cure all types of STIs. 9. T? F Using a condom when you have sex will help protect you against STIs. 10. T? F Contact with a dirty toilet seat is a common cause of STIs. 11. T? F If you have an STI your sexual partner probably has it too. 12. T? F Condoms are 100% effective against STIs. 13. T? F There is a bigger chance of getting an STI if you have sex with many people. 14. T? F There is a bigger chance that a woman will get an STI if she has sex with a guy who has sex with many other women. 15. T? F Having anal sex with a guy (i.e., his penis in your anus/behind) increases your chance of getting AIDS, compared to having vaginal sex (his penis in your vagina). 16. T? F When using a condom, adding Vaseline as a lubricant lowers the chance of getting an STI. 17. T? F When using a condom, adding a spermicide (birth control foam or jelly containing Nonoxynol-9) lowers the chance of getting an STI. Page 3

4 18. T? F Doing oral sex on a guy (your mouth on his penis) increases your chance of getting AIDS, compared to having vaginal sex (his penis in your vagina). 19. T? F You can not get an STI if you have sex with only one person during your whole life. 20. T? F The penis should be erect (hard) when the condom is put on it. 21. T? F When a condom is placed on the penis, space should be left at the tip of the condom. 22. T? F The condom should be completely unrolled before it is placed on the penis. 23. T? F Condoms can be reused. 24. T? F To remove a condom after sex, grasp the tip and remove it gently but swiftly. 25. T? F Storing or carrying condoms in a hot or warm place can destroy their effectiveness. 26. T? F It is safer to use two condoms, one on top of the other, than to use only one condom. 27. T? F There are no cures for STIs that are caused by bacteria. 28. T? F You will get tested for all STIs in a regular check-up. 29. T? F STIs that are caused by a virus can be cured with antibiotics. 30. T? F Having sex without a condom is safe if he pulls out. 31. T? F You can get one test that will tell you if you have any STIs. 32. T? F Taking a shower before and after sex will help keep you from getting an STI. 33. T? F The more people your partner has sex with, the more likely he is to give you an STI. 34. T? F It's easier for a younger woman's cervix to get infected with an STI. 35. T? F Masturbating is safer than oral sex. 36. T? F Most people who get STIs get them from people who didn't even know they had one. 37. T? F It is usually better to wait and see if an STI will go away by itself before getting medicine. 38. T? F A pap test or pap smear will test you for all STIs. 39. T? F People with bacterial vaginosis (BV) probably got it from a guy. 40. T? F Bacterial vaginosis (BV) can cause problems with pregnancy. Page 4

5 Please circle the STI or STIs below each question to answer. Circle "I don't know" if you have no idea. 1. Which STI attacks the body's immune system? (circle one) 2. Which STI can cause a rash on the palms of your hands and the soles of your feet? (circle one) 3. Which STI can give you painful sores or blisters around the genital area? (circle one) 4. Which STI do more people get every year than any other? (circle one) 5. Which STI looks like a tiny tadpole? (circle one) 6. Which STI can give you liver damage? (circle one) 7. Which STI gives you little bumps on your skin that can look like a tiny cauliflower? (circle one) Page 5

6 The following questions can have more than one answer. If you don t know all of them, circle the ones that you do know. 8. Which 4 STIs are caused by viruses? (circle four) 9. Which 3 STIs give you unusual discharge from your vagina? (circle three) 10. Which 2 STIs give you bumps, blisters or lesions in the genital area? (circle two) 11. Which 4 STIs can be cured? (circle four) 12. Which 2 STIs are usually passed on by skin-to-skin contact? (circle two) 13. Which 2 STIs, if left untreated, commonly lead to PID, or Pelvic Inflammatory Disease? (circle two) 14. For which 2 STIs can symptoms go away and then the same symptoms come back? (circle two) 15. From which of the following STIs do people usually die if they have? Page 6