Health Center / Clinic Survey
1. Did you come here today to get tested for sexually transmitted diseases (STDs)?
Yes
No
I came for other reasons but I want to get tested for STDs today
2. Have you seen or heard of the GYT: Get Yourself Tested campaign?
Yes
No
Not sure
3. If you are here for an STD test, did you come in because of the GYT: Get Yourself
Tested campaign?
No, I have never heard of the GYT campaign [skip to Question 6]
No, I had planned to get an STD test for other reasons [skip to Question 6]
Yes, I had been thinking about getting tested and the GYT campaign helped me
decide to get tested
Yes, I had never considered getting tested but the GYT campaign helped me
realize that I should
4. Where have you seen or heard about the GYT: Get Yourself Tested campaign?
(Check all that apply)
Ad or article in a magazine MTV
or newspaper TV (other than MTV)
Billboards Posters
Blogs Promotional items (e.g. buttons
Buses or subways or stickers)
College campus Radio
Community events Text message
Email TV news (other than MTV news)
Facebook Twitter
Flyers Web site
Foursquare YouTube
Friends Other [specify: ____________ ]
5. Did you talk about STD testing or sexual health with any of the following people because
of the GYT: Get Yourself Tested campaign? (Check all that apply)
A doctor, nurse, or other medical provider
Your partner
A friend
Parent(s) or caregiver
Other family members
Other [specify: ________ ]
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Health Center / Clinic Survey
6. Have you been tested for an STD in the last 12 months?
Yes
No
Not sure
7. What is your gender?
Female
Male
Don’t want to identify
8. What is your race? (Check all that apply)
White, non Hispanic
Black, non Hispanic
Hispanic or Latino
Asian or Pacific Islander
Native American or Hawaiian
Other
9. How old are you?
_________________________
10. What state do you currently live in?
_________________________
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