Section One: Facts About You like to ask some questions about you. We are not going to use this information to identify you, but instead to First, we’d talk about what different groups of people have to say. For example, what boys have to say, and how that may be different from what girls have to say. Or how 12-year-olds feel about different things, and how that might be different from what 17-year-olds feel. How would you describe yourself? (Gender) How would you describe yourself? (Sexual orientation) Male  Female Straight or heterosexual   Other (Specify________) Bisexual   Gay or lesbian  In what year were you born? (Enter all four digits Unsure  of the year in the boxes below, and fill in corresponding circles) What is your primary spoken language? (Chinese, Japanese, or other) 1 0 0 0 Indian (Apache, Blackfoot, 1 1 1 Navajo, or other) 2 2 2 3 3 3 4 4 4 How well do you speak English? 5 5 5 6 6 6 7 7 7 Very well  8 8 8 Well  9 9 9 Not well  Not at all  Are you of Hispanic, Latino/a, or Spanish origin? (If yes, you may select one or more Do you have any health issues that affect your ability to see, hear, move around easily, or do categories) self-care like dress yourself or brush your teeth? No, not of Hispanic, Latino/a, or Spanish origin Yes, Mexican, Mexican American, Chicano/a Yes, Puerto Rican Yes  Yes, Cuban No  Yes, another Hispanic, Latino/a, or Spanish origin With whom do you live? (Mark all that apply) Alone  What is your race? (Select one or more) With parents  With relatives other than parents  White  With a foster family  Black or African American  With roommates American Indian or Alaska Native   Other  Asian Indian  Chinese  Describe where you live. Filipino  Japanese  In my own home or apartment  Korean  In a home  relative’s Vietnamese  In a group home  Other Asian  In campus/dormitory housing  Native Hawaiian  In a foster  Guamanian or Chamorro  Homeless or in a shelter  Samoan  Other  Other Pacific Islander 
Section One: Facts About You First, we’d like to ask some questions about you. We are not going to use this information to identify you, but instead to talk about what different groups of people have to say. For example, what boys have to say, and how that may be different from what girls have to say. Or how 12-year-olds feel about different things, and how that might be different from what 17-year-olds feel. How would you describe yourself? (Gender)  Male  Female  Other (Specify________) In what year were you born? (Enter all four digits of the year in the boxes below, and fill in corresponding circles) Are you of Hispanic, Latino/a, or Spanish origin? (If yes, you may select one or more categories) No, not of Hispanic, Latino/a, or Spanish origin Yes, Mexican, Mexican American, Chicano/a Yes, Puerto Rican Yes, Cuban Yes, another Hispanic, Latino/a, or Spanish origin What is your race? (Select one or more)  White  Black or African American  American Indian or Alaska Native  Asian Indian  Chinese  Filipino  Japanese  Korean  Vietnamese  Other Asian  Native Hawaiian  Guamanian or Chamorro  Samoan  Other Pacific Islander How would you describe yourself? (Sexual orientation)  Straight or heterosexual  Bisexual  Gay or lesbian  Unsure What is your primary spoken language? (Chinese, Japanese, or other) Indian (Apache, Blackfoot, Navajo, or other) How well do you speak English?  Very well  Well  Not well  Not at all Do you have any health issues that affect your ability to see, hear, move around easily, or do self-care like dress yourself or brush your teeth?  Yes  No With whom do you live? (Mark all that apply)  Alone  With parents  With relatives other than parents  With a foster family  With roommates  Other Describe where you live.  In my own home or apartment  In a relative’s home  In a group home  In campus/dormitory housing  In a foster  Homeless or in a shelter  Other 3 3 1 2 3 4 5 6 1 0 1 2 4 5 6 7 8 9 0 1 2 4 5 6 7 8 9 0 7 8 9
HIV%20Youth%20Questionnaire_Revised2016.docx