Internet Survey Purpose: This survey and your participation in it are vital in helping us to create better marketing materials that speak directly to our community. The materials will feature images and messages about safer sex, positive body images and where to get services. This survey is voluntary and anonymous so please be as honest as possible. Current Age Date of Birth / / Bronx Manhattan [1[ Gender 1.Male 2.Female 3.Transgender (TG) 3.1M to F 3.2F to M 4.Other_______
[5] Race 1.African American/Black 2.Asian Amer/Pac. Is./Filipino 3.Caucasian/White 4.Native Amer/ Amer. Ind. 5.Mixed Heritage 6.Other
[2] Sexual Orientation 1.Gay/Lesbian 2.Bisexual 3.Heterosexual 4.Down Low (DL) 5.Questioning 6.Men who have Sex with Men (MSM) 7.Same Gender Loving (SGL) 8.Other
[6] Enter the Zip code you reside in
[3] Age
[4] Ethnicity
1.13-16 2.17-20 3.21-24 4.25-36 5.37-49 6.50 & over
1.Hispanic 2.Not Hispanic/Latino 3.Ethnicity Unknown
[7] Highest Education
[8] HIV Status
1.Some High School 2.High School 3.GED 4.Some College 5.College 6.Post Grad 7.Other_____
1.Positive 2.Negative 3.Don’t Know 4.Prefer not to answer
Please check all that applies: 1. How do you access the internet? Home Computer
Work Computer
Internet Café
Friends or Family
2. How do you connect to the internet? Dial up
DSL
Cable
Other
3. What type of computer do you use when on the internet? Dell
Gateway
Compaq
HP
Mac
Other
4. What operating system to you use? Select One 5 If you belong to any online groups please list the top (3) groups here: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ___ 6. Who are the (2) most “popular” screen names and on what site do you find them? _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ___ 7. What is your favorite site for “socializing”? , , _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ___ 8. What is your favorite site for “hook-ups”? , , _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ___ Do you use recreational drug or drink when you have sex? Select One If yes, list the (2) favorite _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ___ Within the last (6) month, have you had vaginal or anal sex without a condom Select One
Thank you for your participation in this survey. Revised 4.6.05