Instructions: Module 20 - TheMeasurementGroup.com

Citation: Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1996). Module 20: HIV/AIDS Risk Behavior 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.

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 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, "96" for 1996). 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.

Note: This module is intended to be administered as a semi-structured interview. A semi-structured interview is one in which you are guided by question formats. However, you need not use the question format in a verbatim or absolutely standardized fashion, only as a guide to elicit a valid response. You should use your best judgment in using a combination of direct observation, informal conversation, and direct questions in eliciting responses. Information on behaviors may best be gathered through direct observation. If you have direct knowledge of the client’s behaviors, you may not want to use the question format. Additionally, an informal conversation may yield more accurate information than questions in the format outlined below, so you should use your best judgment in obtaining valid and accurate information for this section.

If you wish to use the direct question format, start by asking the client if he/she ever engaged in the behavior. If no, darken the circle next to "no" and then skip to the next item. If yes, ask if he/she engaged in the behavior in the last 24 hours. If the client has engaged in the behavior within the last 24 hours darken the circle next to "TODAY, last 24 hours."

If the client has not engaged in the behavior within the last 24 hours, ask if he/she engaged in the behavior in the last 30 days. If yes, darken the circle next to "CURRENT, happened in the last 30 days, not today."

If the client has not engaged in the behavior in the last 30 days, darken the circle next to "EVER, happened but not in the last 30 days."

If the client refuses to answer the question, darken the circle next to "REFUSED." If the client does not know if he/she has ever practiced the behavior, darken the circle next to "DON’T KNOW."

Behavior	Working Definition
Sex With Males	If client has sex, including oral, anal, or vaginal sex, with males.
Unprotected Sex With Males	If client has sex with males without using a condom or other latex protection, such as dental dams.
Sex With Females	If client has sex, including oral, anal, or vaginal sex, with females.
Unprotected Sex with Females	If client has sex with females without using a condom or other latex protection, such as dental dams.
Sex with IDU	If client has sex with someone who has injected drugs or is currently injecting drugs.
Sex Work / Survival Sex	If client engages in the exchange of sex for money, drugs, a place to stay, or other goods.
Sex with HIV+ Person	If client has sex with someone who is known to have tested HIV positive.
STD (not HIV)	If client has a sexually transmitted disease other than HIV, such as gonorrhea, chlamydia, syphilis, herpes, etc.
Injection Drug Use	If client injects drugs intravenously or intramuscularly (skin popping).
Needle Sharing	If client shares needles with others in the course of injecting drugs.
Received Blood Transfusion	If client has received a transfusion of blood.
Cigarette Smoker (1/2 pack or more a day)	If client smokes 1/2 pack or more (10 or more) tobacco cigarettes daily, on the average.
Inferred Alcohol Problem	If service provider infers an alcohol problem based on clinical judgment, or if client reports an alcohol problem.
Heroin Use	If client uses heroin (china white, smack).
Crack Use	If client uses crack cocaine (rock).
Other Illicit Drug Use	If client uses other illegal, non-prescribed, drugs (forms of cocaine other than crack, methamphetamines, PCP, hallucinogens, etc.)
CJS Involved	If client is involved with any aspect of the criminal justice system (including arrests, convictions, incarcerations, probation, etc.).