This toolkit was originally developed by PC Cameroon. The original has been revised by OPATS for wide use and to include global health indicators. Please revise to align with your programming as needed.

Community ______

Date received ______

Form ______

Number ______

General Questions:

  1. How old are you?
  2. 13 years or younger
  3. 14 years
  4. 15 years
  5. 16 years
  6. 17 years
  7. 18 years or older
  1. What is your sex?
  2. Boy
  3. Girl
  1. What tribe are you?
  2. Kusaasi
  3. Mamprosi
  4. Mosi
  5. Hausa
  6. Busanga
  7. Other (please write in):

______

  1. What religion are you?
  2. Muslim
  3. Catholic
  4. Seventh Day Adventist
  5. Pentecost
  6. Other (please write in):

______

  1. What work does your father do?
  2. Farmer
  3. Merchant / Trader
  4. Teacher
  5. Tailor
  6. Other (please write in):

______

  1. What work does your mother do?
  2. Seamstress
  3. Farmer
  4. Nurse
  5. Merchant / Trader
  6. Stays at home
  7. Other (please write in:)

______

  1. How many boy children are in your house?
  2. 0
  3. 1-3
  4. 3-5
  5. 6 or more
  1. How many girl children are in your house?
  2. 0
  3. 1-3
  4. 3-5
  5. 6 or more
  1. How many adults are in your house?
  2. 0
  3. 1-3
  4. 3-5
  5. 6 or more
  1. How many children (except small babies) in your house are not attending school?
  2. 0
  3. 1-3
  4. 3-5
  5. 6 or more

Gender Role Questions:

Circle all that Apply

  1. Who fetches water for your house?
  2. The father
  3. The mother
  4. The boys
  5. The girls
  1. Who cleans the compound at your house?
  2. The father
  3. The mother
  4. Girl child
  5. Boy child
  1. Who cares for babies at your house?
  2. The father
  3. The mother
  4. Girl child
  5. Boy child
  1. Which child is it most important to send to school?
  2. Girl child
  3. Boy child
  4. Both Boy and Girl children
  1. Who works at your farm?
  2. The father
  3. The mother
  4. Boy child
  5. Girl child
  1. Who looks after your animals?
  2. The father
  3. The mother
  4. Girl child
  5. Boy child
  1. Who gives money for food in the family?
  2. The father
  3. The mother
  4. Both mother and father
  5. Other (please write in): ______
  1. Who is it to think about family planning/ the number of children a family should have?
  2. The father
  3. The mother
  4. Both mother and father
  1. Is it okay for a woman to ask a man to use a condom during sex?
  2. Yes
  3. No
  1. Who suggests the use of a condom during sex?
  2. The man
  3. The woman
  4. Both the man and the woman
  1. Who makes the decision to have sex?
  2. The man
  3. The woman
  4. Both the man and the woman
  1. Is it okay for a boy to beat a girl?
  2. Yes
  3. No
  1. How often do you see boys beating girls?
  2. Everyday
  3. 1-2 times a week
  4. 1-2 times a month
  5. Never
  1. Is it okay for a girl to beat a boy?

a.Yes

b.No

  1. How often do you see girls beating boys?
  2. Everyday
  3. 1-2 times a week
  4. 1-2 times a month
  5. Never

Sexual Activity Questions:

  1. Have you ever had sexual intercourse before?
  2. Yes
  3. No
  1. How old were you when you first had sex?
  1. 12 years or younger
  2. 13-15 years
  3. 16-18 years
  4. 18 years or older
  5. Never had sex
  1. How many people have you had sexual intercourse with?
  2. One person
  3. 2 –3 people
  4. 3 or more people
  5. Never had sex
  1. Have you ever had sexual intercourse without a condom?

a.Yes

b. No

c.Don’t Know

d.Never had sex

  1. The last time you had sex did you or your partner use a condom?
  2. Yes
  3. No
  4. Don’t Know
  5. Never had sex
  1. Do you regularly use condoms when having sex?

a. Yes

b. No

c. Never had sex

  1. The reason I do not use condoms is
  2. My partner doesn’t like them
  3. I don’t like them
  4. They’re too expensive
  5. I don’t know how to use them
  6. I’m too embarrassed to buy them
  7. Never had sex
  8. Other (please write in reason): ______
  1. Did you ever test for HIV?
  2. Yes
  3. No
  4. Don’t know
  1. Have you ever had any other sexually transmitted infection (STI)?
  2. Yes
  3. No
  4. Don’t Know
  1. Have you ever been treated for an STI?
  2. Yes
  3. No
  4. Never had an STI
  1. Has anyone in your family ever informed you about safe sex?
  2. Yes
  3. No
  1. Has anyone in your family ever informed you about condoms and/or how to use them?
  2. Yes
  3. No

HIV/AIDS Questions:

  1. Where have you heard about HIV/AIDS?

Circle all that apply

  1. in school
  2. in church/mosque
  3. at home/family
  4. friends/schoolmates
  5. Clubs
  6. Other (please write in:)

______

  1. Is your family aware of HIV/AIDS?
  2. Everyone is aware
  3. Most people are aware
  4. Some are aware
  5. No one is aware
  6. Don’t Know
  1. Do you know someone with HIV or AIDS?
  2. Yes
  3. No
  4. Don’t know
  1. Do you know someone who died of AIDS?
  2. Yes
  3. No
  4. Don’t know
  1. Why do you think people become HIV positive?

Circle all that apply

  1. They have had unprotected sex
  2. They have been cursed
  3. They use illegal drugs
  4. They have been infected from a mosquito
  5. They were born with HIV
  6. They have had sex with many people
  7. I don’t know why people are infected with HIV
  1. Should we still remain friends with people living with HIV and AIDS?
  2. Yes
  3. No
  1. Is there a cure for HIV/AIDS?
  2. Yes
  3. No
  4. Don’t know
  1. Is HIV spread through unprotected sex (sex without a condom)?
  2. Yes
  3. No
  1. Can you get tested for HIV in Bawku?
  2. Yes
  3. No
  4. Don’t know
  1. Can you cure HIV/AIDS by sleeping with a virgin?
  2. Yes
  3. No
  4. Don’t know
  1. Can you get HIV by shaking hands with someone who is HIV positive?
  2. Yes
  3. No
  4. Don’t know
  1. Can you get HIV by eating from the same bowl with someone who is HIV positive?
  2. Yes
  3. No
  4. Don’t know
  1. Is it okay to use the male and female condom at the same time when having sex?
  2. Yes
  3. No
  4. Don’t Know
  1. Is it okay to use a male condom more than once?
  2. Yes
  3. No

c. Don’t Know

  1. How effective are condoms at preventing HIV?
  2. Very effective
  3. Somewhat effective
  4. Not at all effective
  1. Can people living with HIV and AIDS still live good lives?
  2. Yes
  3. No
  1. If a pregnant woman has HIV or AIDS will her baby be born with HIV?
  2. Yes
  3. No
  1. Can you tell by looking at someone if they are HIV positive?
  2. Yes
  3. No
  4. Don’t know
  1. Which ages are most at risk for HIV infection?
  2. People 15-24 years old
  3. People over 24 years old
  4. Don’t know
  1. Who is the most at risk for HIV infection?
  2. Boys / Men
  3. Girls / women
  4. Don’t know
  1. Is HIV/AIDS a serious problem in Ghana?
  2. Yes
  3. No
  4. Don’t know
  1. Is HIV/AIDS a serious problem in Bawku East district?
  2. Yes
  3. No
  4. Don’t know
  1. Is HIV/AIDS a serious problem in your school?
  2. Yes
  3. No
  4. Don’t know

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