Circle one.
| 1. | Are you male or female? | M | F |
| 2. | Have you purchased a condom within the last 6 months? | Y | N |
| 3. | Have you ever had unprotected intercourse (no protection)? | Y | N |
| 4. | Have you had unprotected intercourse within the last 6 months? | Y | N |
| 5. | Have you ever had intercourse using a condom for protection? | Y | N |
| 6. | Have you had intercourse using a condom within the last 6 months? | Y | N |
| 7. | Have you ever been treated for a sexually transmitted disease? | Y | N |
| 8. | Have you ever had an HIV test? | Y | N |
| 9. | Have you ever encouraged your peers to practice safer sex? | Y | N |
| 10. | Have you ever chosen abstinence as an option? | Y | N |
| 11. | If in an intimate relationship, are you comfortable discussing safe sex? | Y | N |
Rate each of the following methods of protection according to effectiveness of disease prevention. Use the scale of one to five. (1 = least effective and 5 = most effective.)
____ Early withdrawal
____ Douching after intercourse
____ Hoping (using no protection)
____ Rhythm method
____ Birth control pill
____ IUD
____ Norplant underarm implant
____ Abstinence
____ Latex condom
____ Contraceptive foam
____ Secondary Virginity
____ Contraceptive Sponge
____ Female condom
____ Dental dam
| ____ | Unprotected intercourse in a mutually faithful and monogamous relationship, in which both have tested negative for HIV |
Circle one.
| 1. | Are you a male or female? | M | F |
| 2. | Are you more willing to practice safer sex? | Y | N |
| 3. | Would you choose to use a condom for protection as a means of safer sex? | Y | N |
| 4. | Would you choose to practice faithful monogamy, after you and your partner had HIV testing done and had both tested negative? | Y | N |
| 5. | Will you encourage your peers to use a condom as a method of safer sex? | Y | N |
| 6. | Will you encourage your peers to practice abstinence or secondary virginity? | Y | N |
| 7. | Would you chose abstinence or secondary virginity? | Y | N |
| 8. | Will you feel more comfortable negotiating safe sex with your partner? | Y | N |
| 9. | Will you enforce your partner to practice smart sex with you? | Y | N |
| 10. | Would you recommend attending Smart Sex for Men and Women to your friends? | Y | N |
| 11. | What did you think of this Smart Sex program? Your suggestions will be very helpful in planning future programs. |
Thank you for your participation in Smart Sex for Men and Women.
Survey written by Lydia P. Smith, Graduate Assistant/Health Educator, Student Health Services, University of Pittsburgh at Bradford, Bradford, PA 16701, 1995.