Exhibit
__________________________________________________________________
Institutional Condom Assessment Questionnaire
The following questionnaire inquires about the condom distribution procedures at your
college/university (i.e., your institution) as well as the benefits/barriers to condom
programs. We are interested in your opinion even if you do not currently offer condoms to
students. If you have any questions please contact the investigators
Directions: For the following series of questions, any source of condom distribution on
campus that is sanctioned by the college/university should be considered in your response.
Any program or system which makes condoms available to students should be considered a
distribution program.
1. Does your institution distribute (or make available) condoms to students (this includes
giving them to students without charge and/or selling them to students)?
Yes
No
____ (Please skip to Question #6)
____
2. Is your college/university currently considering implementing a condom distribution
program for students?
Yes
No
____
____
3. Is your institution preparing to implement a condom distribution program within the
next academic year?
Yes
No
____
____
4. Has your institution considered offering condoms to students in the past, but decided
against implementing a program?
Yes
____
No
____
Uncertain ____
5. Has a condom distribution program been available at your institution in the past, but
has been discontinued?
Yes
____
No
____
Uncertain ____
6. In your opinion, what are the barriers/challenges to offering a condom distribution
program on your campus? Please mark an “X” next to all that apply:
Administrative objections
Efficacy of condoms
Encourages sexual activity
Expense of condoms
Institutional ideology
Lack of available funds
Lack of effective distribution means
Lack of student demand
Lack of student need
Liability concerns
Objections by clinicians
Parental objections
Policy restrictions
Religious affiliation-based objections
Student objections
____
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Others (please identify): __________________________________________
7. In your opinion, what are the benefits of offering a condom distribution program on
your campus? Please mark an “X” next to all that apply:
Administrative approval
Cost effectiveness
Encourages healthy sexual communication among students
Encourages healthy student behaviors
Encourages interaction with healthcare providers
Encourages sexual responsibility among students
Financial profit for campus organizations, services, or departments
Improves campus image
Parental approval
Provides best possible health care options for student population
Reduce sexually transmitted infections
Reduce unintended pregnancies
Reduction in healthcare expenses
Reduction in healthcare utilization
Student appreciation
____
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Others (please identify): _____________________________________________
Directions: Please read questions 8 through 24. Please place an “X” next to any of the
responses that apply to your institution.
8. How long has your institution distributed condoms on campus?
Less than 1 year
1 to 5 years
6 to 10 years
More than 10 years
Do not distribute condoms
____
____
____
____
____
9. Does your institution publicize the availability of condoms on campus?
Yes ____
No ____ (skip to question #11)
Do not distribute condoms ____ (skip to question #12)
10. How does your institution publicize the availability of condoms on campus? Please
mark an “X” next to all that apply:
Brochures
Campus newspaper
Campus television
Campus website
Clinical appointments
Emails
Faculty lectures
Fliers
Peer educator/helper outreach
Phone book
Posters
Residential advisors
Social networking website (e.g., Facebook, Myspace)
Staff outreach
Text messaging
____
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Others (please identify): _____________________________________________
11. If your institution distributes condoms on campus but does not publicize the availability
of condoms, what are the reasons for not publicizing your program?
Do not distribute condoms
Concerns about creating campus controversy
Do not want to promote condom use
Lack of funding
Do not want to promote sexual activity
Do not want to appear to promote sexual activity
Administrative objections
Policy restrictions
____
____
____
____
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____
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Others (please identify): _____________________________________________
12. The items below inquire about your current employment of staff/volunteers involved
with condom issues on your campus. This includes individuals who give condoms to
students, meet with students regarding the use of condoms, teach students about
condom use, and/or advocate for condom education/distribution programs. Please
mark an “X” next to any that apply:
Academic advisor
Administrative assistant
Athletic coach
Campus administrator
Faculty member
Health center director
Health educator
Mental health counselor
Nurse practitioner
Nurse
Physician assistant
Physician
Psychiatrist
Psychologist
Residential advisor
Sexual Assault Nurse Examiner (SANE)
Sexuality educator
Sexuality program coordinator
Social worker
Spiritual/religious counselor (e.g. priest, rabbi)
Student peer helper/educator
____
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Other (please identify): _________________________
13. Some institutions utilize volunteer or paid student peer educators/health helpers. Please
mark an “X” next to any of the following that apply to your institution. Student peers are
used…
To organize condom-related events on campus
____
To conduct condom outreach
(e.g., give presentations at residence halls/Greek housing) ____
To conduct counseling on condom-related issues
____
To give away condoms at campus events
____
To give away condoms at bars
____
To give away condoms at restaurants
____
Other (please identify): _______________________________
14. Please indicate any of the following safer sex products your institution distributes to
students. Please mark an “X” next to all that apply:
Male latex condoms (without spermicide)
____
Male latex condoms (with spermicide)
____
Male flavored condoms
____
Male non-latex condoms
____
Condoms above average size
____
Condoms below average size
____
Female condoms
____
Sexual lubricants
____
Latex dams (i.e., dental dams)
____
Flavored latex dams
____
Condom carriers (i.e., pouches or cases for condoms) ____
Latex gloves
____
Non-latex gloves
____
Other (please identify): _______________________________
**Approximately how many condoms does your institution distribute to students
per year? (If you do NOT distribute condoms please write in 0)__________________
15. If your institution distributes condoms please mark an “X” next to all methods used to
distribute them (including both selling and giving them away).
At bars near or on campus
At campus athletic events
At campus bookstore
At campus events
At campus grocery store
At campus library
At restaurants near or on campus
At the pharmacy
At the student health center/health services after hours
At the student health center/health services
At counseling services
At student organization office (e.g. Gay-Straight Alliance)
In academic department offices/lounges
In campus restrooms
In campus vending machines
In residential halls
Through appointment with health care provider
Through campus mailings
Through educational outreach
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Other (please identify): _______________________________
16. Are students required to undergo an educational/counseling session with a health
provider in order to receive condoms?
Yes
____
No
____
Do not distribute ____
17. On your campus do students purchase condoms, receive them for free, or both?
Purchase them
Receive them for free
Both
Do not distribute
____
____
____
____
18. If your campus distributes condoms to students, what is the limit on the number of
condoms they can receive?
Please specify policy___________________________________
No limit ____
19. Does your institution receive condoms for free (e.g, from a state/local public health
institution, condom company, or other organization)?
Yes
____
No
____
Do not distribute ____
20. Are any of the condom distribution efforts on your campus sponsored by an outside
organization (e.g., Planned Parenthood)?
Yes
____
No
____
Do not distribute ____
21. Are there any student groups or organizations on your campus that distribute condoms
to students?
Yes
No
____
____
22. Does your campus sponsor a condom-related special event such as National Condom
Day, World AIDS Day, or Safe Spring Break Week?
Yes
No
____
____
23. Does your institution refer students to outside organizations (e.g., Planned Parenthood
or local/state public health departments) for condoms or condom-related concerns?
Yes
No
____
____
24. Are there any student groups or organizations on your campus that advocate for
condom-related policies?
Yes
No
____
____
Directions: The items below ask about your institutional demographics. Please respond by
writing in your response or by placing an “X” in the space provided.
25. In which state is your college/university located? _____________________
26. Total student population at your college/university:________________
27. Do you have a student health center/health services on your campus?
Yes
No
____
____
28. If you have a student health center/health services on your campus, what is the total
number of employees/volunteers on staff? _________________
29. Type of Academic Institution:
Public
_____
Private
_____
30. Setting of Your Institution:
Urban
Small Town
Suburban
Rural
_____
_____
_____
_____
31. Student Population:
Primarily Residential
Primarily Commuter
Equal Numbers Residential and Commuter
_____
_____
_____
32. Degrees Awarded at Your Institution (check all that apply):
Associate
_____
Baccalaureate
_____
Masters
_____
Doctorate
_____
Professional (e.g., MD, JD)
_____
Other Degrees
_____
33. Does your institution have a medical school?
Yes _____
No _____
34. Additional Demographic Characteristics (Please check all that apply):
Historically Black Institution
_____
Historically Hispanic Institution
_____
Faith-Based Institution
_____
All Male Institution
_____
All female Institution
_____
Military Institution
_____
Other (please specify): ___________________________
Thank You for Participating in Our Study!