Survey Tool Dummy Table

DUMMY TABLE
QUESTION
Have you ever heard of
AIDS or of the Human
Immunodeficiency Virus
(HIV)that causes AIDS?
NUMBER OF RESPONDENTS
Yes
No
Not sure
NUMBER OF
RESPONDENTS
Yes
No
If YES, through which

source did you hear
about HIV or AIDS?
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
RADIO
TELEVISION
BILLBOARD or FLYERS
NEWSPAPER / MAGAZINE
SPOUSE
OTHER SEXUAL PARTNER
FAMILY MEMBER
DOCTORS OR NURSES
INFECTED PERSONS
COMMUNITY
LEADERS/MEETINGS
SCHOOL
CHURCH / MOSQUE
FRIENDS
OTHER (SPECIFY)
No response
NUMBER OF
RESPONDENTS
If you heard about HIV or
AIDS from a family
member, who did you
hear from?
A.
B.
C.
D.
PARENT
CHILD
OTHER ADULTS
OTHER, SPECIFY
NUMBER OF
RESPONDENTS
Apart from HIV/AIDS, there are other diseases that men

and women can catch by having sexual intercourse. Have
you heard of any of these diseases?
QUESTION
Yes
Yes ___
No ____
No
Not Sure
Is it possible to cure HIV-AIDS?

Can someone die from AIDS?
Can a person infected with HIV
look healthy?
People can take a simple test
to find out whether they have
HIV
NUMBER OF
RESPONDENTS
Yes
No
ways that a person can
protect themselves from
becoming infected with
HIV/AIDS.
A. Abstain from sex

B. Use of condom
C. Stay faithful to one
partner
D. Limit number of sexual
partners
E. Avoid sex with
commercial sex workers
F. Avoid sex with persons
who have many sexual
partners
G. Avoid sex with
homosexuals
H. Avoid sex with persons
who inject illegal drugs
intravenously
I. Avoid blood transfusions
with untested blood for
HIV
J. Avoid using unsterilized
needles and injections
K. Avoid kissing
L. Avoid mosquito bites

M. Seek protection from
traditional healers
N. Avoid sharing razors,
blades, or any sharp
objects
O. Require partner to take
HIV test
P. Others, please specify:
NUMBER OF
RESPONDENTS
Yes
No
Please tell me all the ways
that a
mother can transmit
HIV/AIDS to her
baby?
A.
B.
C.
D.
E.
During Pregnancy
During Labor/Delivery
Through Breast Milk
Other, Specify
Dont Know
QUESTION
If a person is in possession of a male condom, it implies they are

planning to have sex.
Using a male condom reduces sexual pleasure.
A man will be offended if a woman insists that he should use a
condom.
It is embarrassing to buy or ask for condoms.
Men need to have more than one sexual partner.
Women need to have more than one sexual partner.
Sexual intercourse should only take place between married
couples
On the issue of HIV/AIDS, a person can safely accept blood
transfusion if the blood have been screened for HIV/AIDS.
It is safe to share sharp objects such as clippers, nail cutters,
razor blades, etc with friends or family members.
The sharing of equipment (without washing) to perform
circumcision on boys and girls can expose them to HIV infection
and AIDS.
The use of unsterilized equipment to perform circumcision on
boys and girls can expose them to HIV infection and AIDS.
NUMBER OF
RESPONDENTS
1
2
3
4
QUESTION
Yes
No
Not Sure
Have you ever heard about Voluntary Counselling and Testing
for HIV/AIDS?
Have you ever had a test for HIV, the virus that causes AIDS?
LAST 12 MONTHS
BETWEEN 1-5 YEARS
AGO
If YES, when was the first time?
MORE THAN 5 YEARS
AGO
DONT KNOW
NUMBER OF
RESPONDENTS
Yes
No
Not sure
Did you receive the results of your first test?
What is your HIV status?
If you have been tested and counselled

for HIV more than once, when was the
MOST RECENT time?
If you have NEVER been tested, why

have you NOT been tested?
Positive
Negative
Dont know
Last 12 months
Between 1-5 years ago
More than 5 years ago
Dont know
Not likely to have HIV infection
Afraid to find out that I am
infected
Prefer not to think about HIV
Do not like needles or blood
drawing
Worried that test results would
not
Remain confidential
Afraid of losing job, family,
housing ,
Friends if found to be infected
Not sure how to tell spouse or

other
Sexual partner if infected
Do not know where to be tested
and
Counselled
Other (specify)
Not sure/ dont know
Approximately, how many injections of
medicine have you received in the last
12 months?
None
Record number of injections
Dont know
Approximately, how many blood

transfusions have you received in the
last 12 months?
None
Record number of injections
Dont know
QUESTION
Have you ever heard about Antiretroviral drugs for HIV/AIDS?

Antiretroviral drugs can cure HIV/AIDS
Antiretroviral drugs can prolong the life of people infected with
HIV/AIDS.
People can easily get into an Antiretroviral treatment program if
they have HIV/AIDS.
NUMBER OF
RESPONDENTS
Yes
No
Not sure
QUESTION
What do you do to
avoid getting infected
with HIV/AIDS?
NUMBER OF
RESPONDENTS
Yes
No
Advise spouse/sexual partner to take

care
Prayer can protect
Practice sexual abstinence
Use Condoms with:
A. All other partners except spouse
B. Commercial sex workers/Bar girls
C. People from town
D. People you think might be infected
Avoid having sexual intercourse with:
A. Any partners except spouse
B. Commercial sex workers/Bar girls
C. Many Partners
D. People from town
E. People you think might be infected
F. People of the same sex
Others:
A. Avoid blood transfusions and
injections
B. Nothing can be done
C. Other (Specify) ____________________
D. Dont Know
QUESTION
Yes
No
We want to make certain that we have the correct

information. Have you ever had sexual intercourse in
your whole life?
If yes, Do you have a regular sexual partner?
If no, please proceed to the next part.
Do you have a spouse or regular sexual
partner?
No
Yes, Spouse
Yes, Other Regular
Partner
**In your whole life how many people have you had
sexual intercourse with?
Number:
**About how old were you when you first had sexual intercourse?
Age:
**How long ago did you last have intercourse with a

woman/man?
Years
Month
Weeks
Days
The last time you had sex with your spouse or regular partner, did you or your
partner use a condom?
How often do you use a condom with your spouse or regular partner?
Yes:
No:
Always
Usually
Not often
almost never
NUMBER OF
RESPONDENTS
Yes
No
Not sure
Have you ever been formally instructed on how to use a condom?

Have you had any sexual partners (aside from/a your spouse or regular sexual partner) in the
past THREE months?
If YES, the last time you had sex with this other sexual partner, did you or this partner use a
condom?
In the last 12 months, have you had sex with a commercial sex
Worker?
If YES, did you use a condom the most recent time you had sex with a commercial sex
worker?
Do you think your spouse or regular partner has other sexual partners?
**In this community, at what age do young men begin having sexual intercourse?
**this community, at what age do young women begin having sexual intercourse?
Age:
Age:
FOR THOSE WHO HAVE NEVER EXPERIENCED SEXUAL INTERCOURSE

QUESTION
NUMBER OF
RESPONDENTS
1
2
3
I don't feel ready to have sex.
I have not had the opportunity.
I think that sex before marriage is wrong
I am afraid of getting pregnant

I am afraid of getting HIV/AIDS or another sexually
transmitted infection.
NUMBER OF
RESPONDENTS
Not
Yes
No
sure
Is it a common practice in this community to have sex for money, gifts, or other favors?
In some places in the world, poor women exchange sex for food or for money that they use to
buy enough food for their families. Do you think that poor women in this community and in
nearby communities have/exchange sex for food or for money to use to buy food for their
families?
In some places in the world, some men or women have sex with other men of women of the
same sex. Have you heard of this type of sexual practice?
Do some men in this community have sex with other men or boys?
Would you consider the practice (of men having sex with men in this community) to be
common?
QUESTION
How worried are you that you might already be infected with HIV/AIDS?
NUMBER OF
RESPONDENTS
Worried a lot
Worried a
little
Not worried at
all
Not sure
NUMBER OF
RESPONDENTS
Yes
No
Not sure
Do you think that your current sexual behavior puts you at risk of infection with
HIV?
Do you think your partners current sexual behavior puts you at risk of infection with
HIV?
QUESTION
People infected with HIV should be ashamed of themselves.
People infected with HIV are promiscuous.
I would feel ashamed if I were infected with HIV.
People infected with HIV should be expelled from their community.
NUMBER OF
RESPONDENTS
3
1
2
4
NUMBER OF
RESPONDENTS
Yes
No
Not sure
QUESTION
Are you aware of any programs from the national government of the Philippines that
are intended to help prevent infection with HIV/AIDS?
Are you aware of any programs from the local government of Malolos, Bulacan that
are intended to help prevent infection with HIV/AIDS?
Are there any local programs or activities from the local government that are intended
to help prevent infection with HIV/AIDS?
If YES, have you had any direct contact with any of these local HIV prevention
programs?
Are there any programs or activities sponsored by local mosques or churches that are
intended to help prevent infection with HIV/AIDS?
If YES, have you had any direct contact with any of these mosque or church
HIV/AIDS prevention programs?
In the last year, have you had any visits to any local clinics, hospitals or doctors
offices?
If YES, while you took part in these visits, were you asked if you had any
concerns or questions about HIV/AIDS
If YES, during any of these visits, were you asked about your risks of
HIV/AIDS?
If YES, while you were on any of these visits, were you given any information
about preventing HIV/AIDS?If YES to SER 99, while you were on any of these
visits, were you given any information about preventing HIV/AIDS?
Do you think that, before they become sexually active, children should be taught
about how to protect themselves from getting HIV/AIDS?
NUMBER OF
RESPONDENT
S
If YES, where and how should that teaching take place?
In The Home
In Church Or Mosque
In Clinics Hospitals Or Doctors
Offices
From Traditional Healer
In Schools
From RADIO, TELEVISION Or
NEWSPAPERS
From Peers And Friends
Other Places, Specify:
Not Sure
For women only:

QUESTION
Have you given birth during the last three years?
If YES, did you receive any antenatal care before giving birth?
If you received such care, did you have an HIV test and counselling while pregnant?
If you had an HIV test and counselling, did you go back to the clinic or doctors office to
receive the results of the HIV test?
NUMBER OF
RESPONDENTS
Yes
No
Not sure

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DUMMY TABLE

If YES, through which

Apart from HIV/AIDS, there are other diseases that men

Is it possible to cure HIV-AIDS?

A. Abstain from sex

L. Avoid mosquito bites

If a person is in possession of a male condom, it implies they are

What is your HIV status?

If you have been tested and counselled

If you have NEVER been tested, why

Not sure how to tell spouse or

Approximately, how many blood

Have you ever heard about Antiretroviral drugs for HIV/AIDS?

Advise spouse/sexual partner to take

We want to make certain that we have the correct

**How long ago did you last have intercourse with a

Have you ever been formally instructed on how to use a condom?

FOR THOSE WHO HAVE NEVER EXPERIENCED SEXUAL INTERCOURSE

I am afraid of getting pregnant

If YES, where and how should that teaching take place?

For women only:

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