Sample Questionnaire
SECTION A. Basic information
i Sex: Male Female
ii Age: 15-30 31-45 46-60 61-75 75 and above
iii Marital status: Married Single Separated/ divorced Widow(er)
iv Please circle here: How many sexual partner(s) do you have? 0 1 2 3 45/more
v Please circle the number with regards your response: What is your current occupation? From
one of the following categories; Non-active, Self-employed, Employed, Not at all
Non- Active Response
i- Responsible for ordinary shopping and looking after the home, or without 1
any current occupation, not working
ii- Student
iii- Unemployed or temporally not working 2
iv- Retired or unable to work through illness
3
Self Employed
i- Farmer 5
ii- Fisher man
iii- Professional (lawyer, medical practitioner, accountant, architect, etc.) 6
iv- Owner of a shop, craft man or other self-employed person 7
v- Business proprietors, owner (full or partner) of a company
8
Employed
i- Employed professional (lawyer, medical practitioner, accountant, architect) 10
ii- General management, director or top management
iii- Middle management, other management (department head, junior manager, 11
teacher, technician) 12
iv- Employed position, working mainly at a desk
v- Employed position, not at desk but travelling (salesmen, driver etc)
vi- Employed position, not at a desk but in a service job (hospital, restaurant,
13
police, fireman, etc.)
1
vii- Supervisor 14
viii- Skilled manual worker
ix- Other (unskilled) manual worker, servant 15
16
17
18
19
Not at all
SECTION B. General view on HIV/ AIDS
2. Have you ever heard of the word HIV- the Human Immunodeficiency Virus that causes
AIDS? Yes No Not Sure No Response
3. If Yes, please thick one or more from either Yes/ No to the response(s) provided from which
you have heard of HIV/ AIDS
Statement Yes No
Radio
Television
Bill board or Hand bills
Newspaper / magazine
Community leaders/meetings
School
Church / mosque
Friends
Family member
Spouse
Other sexual partner
Doctors or nurses
2
Infected persons
Other (specify) ……………………
Don’t know
4. How knowledgeable would you say that you are about HIV/AIDS on a scale where 1 is not at
all knowledgeable, 5 is extremely knowledgeable, the midpoint 3 is moderately knowledgeable
and 6 don’t know/ no response? Circle not more than one response (select any, from 1 to 6).
i Not at all knowledgeable......................................................................................................1
ii Moderately knowledgeable.................................................................................................2
iii Extremely knowledgeable..................................................................................................3
iv Don't know/ No response...................................................................................................4
5. Do you believe that there are people infected with the HIV/ AIDS in Kenema city and Sierra
Leone as a whole? Strongly Agree Agree Uncertain
Disagree Strongly Disagree
6. From what you know or have heard, can you tell me how HIV, the virus associated with
AIDS, is passed on to another person? That is, how people might become infected?
Statement Yes No
Unsafe/unprotected intercourse between a man and a man
Unsafe/unprotected intercourse between a man and a woman
Unsafe/unprotected oral sex
Sharing drug(s) with the use of the same needle(s)
Kissing
Tattoos/body piercing
Contact with physical objects (e.g., fountains, toilette seats)
Blood to blood contact (e.g. from an open cut)
Mosquito bites
Casual contact (e.g., hugging, shaking hands)
3
A sneeze or cough
From mother to child during pregnancy
Other (specify) ………………………………………….
Don't know/No response
7. Please tell me all the ways that a mother can transmit HIV/AIDS to her baby?
I. During pregnancy…………………………………………………………………………...
II. During labour/delivery……………………………………………………………………...
III. Through breast
milk…………………………………………………………………………
IV. Other, specify……………………………………………………………………………….
V. Don’t know………………………………………………………………………………….
8. Please tell me all the ways that a person can protect themselves from becoming infected with
HIV/AIDS? Thick against each in the space provided (Yes or No) base on knowledge.
I. Abstain from
sex…………………………………………………………………………….
II. Stay faithful to one partner………………………………………………………………….
III. Use condoms………………………………………………………………………………..
IV. Limit number of sexual partners……………………………………………………………
V. Avoid sex with commercial sex
workers……………………………………………………
VI. Avoid sex with persons who have many partners…………………………………………..
VII. Avoid sex with homosexuals………………………………………………………………..
VIII. Avoid sex with persons who inject illegal drugs
intravenously……………………………..
IX. Avoid transfusions with blood that has not been tested for
HIV……………………………
X. Avoid unsterilized needles and
injections…………………………………………………...
XI. Avoid kissing………………………………………………………………………………..
4
XII. Avoid sharing razors, blades or any sharp
object……………………………………………
XIII. Require partner to take HIV
test…………………………………………………………….
XIV. Avoid mosquito
bites………………………………………………………………………..
XV. Seek protection from traditional healer……………………………………………………..
XVI. Other (specify) ……………………………………………………………………………...
XVII. No response…………………………………………………………………………………
9. Please circle in the value column to the responses provided against each question, only one
answer per question
Responses Strongly Agree Uncertain Disagree Strongly
Agree Disagree
People infected with HIV should be
ashamed of themselves
A child whose mother was infected with
HIV before his/her birth would also be
positive of the disease
The foetus of a HIV infected pregnant
mother can be prevented from the disease
(HIV)
People infected with HIV has equal right
of belonging, education, employment, and
right to access basic amenities
Individuals at high risk for contracting
HIV include intravenous drug abusers,
those who practice unprotected sex and
prostitutes.
The risk of contracting HIV increases as
the number of one’s sexual partners
increases
5
Condoms are very easy to use
Condoms make sex less enjoyable
Condoms are effective in preventing
pregnancy and sexually transmitted
diseases if properly used