HIV/AIDS Knowledge, Attitudes and Beliefs; Self-Esteem; and Body Image Workshop Survey
HIV/AIDS Knowledge
1. HIV stands for Human Immunodeficiency Virus
a. True
b. False
2. HIV can be transmitted though unprotected sexual intercourse
a. True
b. False
3. HIV CANNOT be transmitted from mother-to-child during pregnancy, birth or breastfeeding
a. True
b. False
4. I can get HIV from using the same toilet as someone who has HIV
a. True
b. False
5. HIV testing can help individuals know their status
a. True
b. False
HIV Attitudes
1. A person who has HIV always looks sick
a. True
b. False
2. People living with HIV deserve respect and support
a. True
b. False
3. Young women should have access to accurate information about HIV prevention
a. True
b. False
4. Adolescent females should have access to HIV testing services
a. True
b. False
5. Knowing one’s HIV status is beneficial.
a. True
b. False
HIV Prevention Skills
1. Using a condom correctly can reduce the risk of HIV transmission
a. True
b. False
2. Discussing HIV prevention with my sexual partner is important
a. True
b. False
3. It is important to discuss HIV prevention with my healthcare provider
a. True
b. False
4. I feel confident that I can make decisions that reduce my risk of HIV
a. True
b. False
5. I feel comfortable asking questions about HIV prevention
a. True
b. False
Self-Esteem
1. I am satisfied with myself most of the time
a. True
b. False
2. I believe I have many strengths
a. True
b. False
3. I feel confident in my ability to succeed in school and in activities I participate in out of school
a. True
b. False
4. I feel confident in social situations
a. True
b. False
5. I believe my friendships are meaningful
a. True
b. False
Body Image
1. I feel comfortable with my appearance
a. True
b. False
2. I often compare my appearance to others
a. True
b. False
3. I feel pressured to look a certain way
a. True
b. False
4. My appearance does not determine my worth
a. True
b. False
5. How I look is more important than the type of person I am
a. True
b. False
Safer Sex Boot Camp Survey
Demographic Information
Age_______
Ethnicity
Hispanic/Latino [ ]
Not Hispanic/Latino [ ]
Race (Please check all that apply)
Black/African American [ ]
Asian [ ]
White [ ]
American Indian/Pacific Islander [ ]
Education (Please check highest level completed)
Elementary School [ ]
Middle School [ ]
High School [ ]
Some College [ ]
College [ ]
Vocational/Trade School [ ]
Income
Less than $10,000 [ ]
$10,000-$15,000 [ ]
$15,000-$20,000 [ ]
$20,000-$25,000 [ ]
$25,000-$30,000 [ ]
$30,000-$35,000 [ ]
More than $35,000 [ ]
Sexual History
1. I have been tested for HIV in my lifetime
a. Yes
b. No
2. How many times have you been tested for HIV?
a. 0 times
b. 1 time
c. 2 times
d. 3 times
e. 4 times
f. 5 times
g. More than 5 times
3. How often do you use condoms?
a. All the time
b. Sometimes
c. Rarely
d. Never
4. How many sexual partners have you had in your lifetime?
a. 1-3
b. 3-5
c. 5-7
d. 7-9
e. 9-11
f. 11-13
g. 13-15
h. More than 15
5. What gender do you have sexual intercourse with?
a. Female
b. Male
c. Both
Previous HIV Education Exposure
1. Have you ever received any formal education about HIV/AIDS?
a. Yes
b. No
2. Has a healthcare provider ever provided you with HIV/AIDS education?
a. Yes
b. No
3. Did you ever learn about HIV/AIDS on social media?
a. Yes
b. No
4. Did you ever learn about HIV/AIDS on television/radio?
a. Yes
b. No
5. Did you ever attend a health fair or community fair where you learned about HIV/AIDS?
a. Yes
b. No
HIV Knowledge
1. HIV stands for Human Immunodeficiency Virus
a. True
b. False
2. HIV can be transmitted through unprotected vaginal or anal sexual intercourse
a. True
b. False
3. HIV can be spread through hugging or shaking hands
a. True
b. False
4. Consistent and correct condom use can reduce the risk of HIV transmission
a. True
b. False
5. HIV can be prevented through the use of pre-exposure prophylaxis (PrEP)
a. True
b. False
HIV Attitudes
1. Women should know their HIV status
a. True
b. False
2. People living with HIV deserve the same respect as others
a. True
b. False
3. I believe I can take steps to protect myself from HIV
a. True
b. False
4. I can look at someone and tell whether or not they have HIV
a. True
b. False
5. I would feel ashamed if I needed an HIV test
a. True
b. False
HIV Skills
1. I am confident in my ability to discuss condom use with a sexual partner
a. True
b. False
2. I feel comfortable talking with a healthcare provider about HIV prevention
a. True
b. False
3. I feel comfortable encouraging my sexual partner to get tested for HIV
a. True
b. False
4. I feel confident in my ability to put a condom on my sexual partner correctly
a. True
b. False
5. I feel confident in my ability to recognize situations that may increase HIV risk
a. True
b. False
Intention to Modify Behavior
1. I will carry a condom in my purse whenever I am going to see my sexual partner
a. Yes
b. No
2. I will tell my partner that we can only have sexual intercourse if we use condoms
a. Yes
b. No
3. I will tell my partner that he/she should be tested for HIV before we have sexual intercourse
a. Yes
b. No
4. I will refuse unwanted sexual activity
a. Yes
b. No
5. I will always discuss sexual health openly with my partner
a. Yes
b. No