Partner Social Support and Stigma Visit Month Screening ID: Participant ID: Visit Date: Site Study Screening Number Site Study Couple I/P Chk dd mm yy Now I am going to ask you some questions about the support you receive from others. Thinking about your current situation, for each of the following ten statements, please respond as much as I would like; less than I or would like; much less than I would like; never. Statements As much Less Much less Never as I than I than I would would like like like 1 I get visits from friends and relatives. 2 I get useful advice important things in my life. 3 I get chances to talk to someone about problems at work or with my housework. 4 I get chances to talk to someone I trust about my personal and family problems. 5 I have people who care what happens to me. 6 I get love and affection. 7 I get support with house related work. 8 I get / would get help with money in an emergency. 9 I get help when I need transportation. 10 I get help when I am sick. All of the A lot Some of the Not at all time of the time time 11 My family, friends, and / or community rely on me financially. 12 My family, friends, and /or community rely on me emotionally. This section deals with feelings you might have if you were to acquire HIV, despite taking the anti-HIV medications. We would like to know what you think regardless of whether these things would actually happen. Please tell me if you or with the following four statements. strongly agree; agree; disagree; strongly disagree Strongly Agree Disagree Strongly agree disagree 13 I would lose friends. 14 My family would disown or neglect me. My community would treat me like an outcast. 15 16 I be treated badly at work or get sacked. (NA) Completed by: (initials/date) _________________________________________ Instruction
Partner Social Support and Stigma Visit Month Screening ID: Site Study Screening Number Participant ID: Site Study Couple I/P Chk Visit Date: dd mm yy Now I am going to ask you some questions about the support you receive from others. Thinking about your current situation, for each of the following ten statements, please respond as much as I would like; less than I would like; much less than I would like; or never. Statements As much as I would like Less than I would like Much less than I like Never 1 I get visits from friends and relatives. 2 I get useful advice important things in my life. 3 I get chances to talk to someone about problems at work or with my housework. 4 I get chances to talk to someone I trust about my personal and family problems. 5 I have people who care what happens to me. 6 I get love and affection. 7 I get support with house related work. 8 I get / would get help with money in an emergency. 9 I get help when I need transportation. 10 I get help when I am sick. All of the time A lot of the time Some of the time Not at all 11 My family, friends, and / or community rely on me financially. 12 My family, friends, and /or community rely on me emotionally. This section deals with feelings you might have if you were to acquire HIV, despite taking the anti-HIV medications. We would like to know what you think regardless of whether these things would actually happen. Please tell me if you strongly agree; agree; disagree; or strongly disagree with the following four statements. Strongly agree Agree Disagree Strongly disagree 13 I would lose friends. 14 My family would disown or neglect me. 15 My community would treat me like an outcast. 16 I be treated badly at work or get sacked. (NA) Completed by: (initials/date) _________________________________________ Instruction
CRF_Social_Support_Stigma-1.docx