1. | What is your first name?* |
2. | What is your age, in years? |
3. | What is your date of birth? |
4. | Where do you live? |
5. | How long have you lived there?* |
6. | How much longer do you think you'll live in (name of the city)? |
7. | Have you ever been to the United States?* |
8. | When was the last time you were in the United States?* |
9. | Do you have any family currently living in the United States?* |
10. | If yes, what family members live in the United States? * |
11. | Have you ever used an illegal drug? |
12. | What drugs have you ever used? |
13. | Have you used any drugs in the past three months?* |
14. | What drugs have you used in the past three months?* |
15. | Have you ever injected an illicit drug?* |
16. | Have you ever had an HIV test?* |
17. | When was the last time you had an HIV test?* |
18. | Have you ever been tested for any sexually transmitted infection such as chlamydia, gonorrhea, or syphilis?* |
19. | When was the last time you were tested for any sexually transmitted infection such as chlamydia, gonorrhea, or syphilis?* |
20. | If you were to test positive for HIV or a sexually transmitted infection such as chlamydia, gonorrhea, or syphilis, would you agree to receive treatment from a doctor? |
21. | Have you ever had sex in exchange for money, drugs, goods or shelter? |
22. | When was the first time that you had sex in exchange for money, drugs, goods or shelter?* |
23. | When was the last time that you had sex in exchange for money, drugs, goods or shelter? |
24. | Are you currently registered with the Municipal Health Services as a Sex worker?* |
25. | What is your marital status?* |
26. | Do you currently have a spouse or steady partner? |
27. | What is your partner's first name?* |
28. | How old is your steady partner?* |
29. | Is your spouse or steady partner male or female? |
30. | How long have you been with your steady partner? |
31. | When was the last time you had sex with your spouse or steady partner? |
32. | How many children do you and your steady partner have together?* |
33. | Who primarily takes care of the children?* |
34. | Does your spouse or partner have any children with other women?* |
35. | Do you have any plans to end your relationship with your spouse or steady partner in the near future? |
36. | If yes, can you please tell me the reason you are thinking about ending your relationship? |
37. | Have you ever experienced any physical, sexual, economic, or verbal abuse from your partner? ++ |
 | Yes |
 | No (skip the rest of the section, to Q42) |
 | Refuse to Answer** |
38. | In the past three months, have you experienced physical, sexual, economic, or verbal abuse from your partner? ++ |
 | Yes |
 | No (skip the rest of the section, to Q42) |
 | Refuse to Answer** |
39. | In the past three months, how often have you experienced abuse from your partner? ++ |
 | Daily |
 | Every month |
 | Occasionally |
 | Almost never |
 | Refuse to Answer** |
40. | In the past three months, how serious would you describe the level of abuse in your relationship with [your partner]? Can you give me some examples? ++, +++ |
 | NONE (for example, has not suffered from any insults, mistreatment or yelling from the partner in the last three months) |
 | MILD (for example, my partner has insulted, swore, or yelled at me at least once in the past 3 months) |
 | MODERATE (for example, my partner has pushed, shoved, or slapped me at least once in the past 3 months) |
 | SEVERE (my partner has punched me, kicked me, or beat me up to the point where I had serious injuries, or has pulled a weapon on me and threatened to kill me one or more times in the past 3 months) |
 | Refuse to Answer** |
41. | Are you currently worried that your life is in danger because of abuse from your partner? ++ |
 | Yes |
 | No |
 | Refuse to Answer** |
42. | Are you currently participating in a research study or program with our group?* |
43. | Specify other research study or program in which respondent is currently participating* |
44. | Would you be willing to come to our office with your spouse or steady partner to see if you are both eligible for a study? |