Participant number
Reversed participant number
Survey Monkey Respondent ID
Survey Monkey Collector ID
Tested for chlamydia in past?
Past: how tested?
Past: how many times self-tested?
Past: source of test?
Other source mentioned?
Past: test from NCSP?
Past: was the test free?
cost of test (if not free)
Past: method of sampling
Other sampling method mentioned?
Past: Method of testing sample
Other testing method mentioned?
Past: diseases tested for
Other diseases tested for?
Past: how happy on receiving result?
Past: how anxious on receiving result?
Past: how relieved on receiving result?
Past: how sad on receiving result?
Past: what was test result?
Past: what did on receiving result?
Past: delay to seeking help
Perception of symptoms in men
Perception of symptoms in women
Treatment control (BIPQ)
Severity 1 (serious health problem)
Vulnerability 1 (anyone can get C)
Severity 2 (infertile)
Fear (feel worried)
Vulnerability 2 (currently at risk)
Severity 3 (stigma)
Subjective Norm Indirect 1 (family)
Subjective Norm Indirect 2 (sexual partner)
Subjective Norm Indirect 3 (friends)
Self-testing Direct Attitude 1
Self-testing Direct Attitude 2
Self-testing Direct Attitude 3
HCP Direct Attitude 1
HCP Direct Attitude 2
HCP Direct Attitude 3
Self-testing Response Costs 1 (expensive)
HCP Response Costs 1 (expensive)
Self-testing Response Efficacy
HCP Response Efficacy
Self-testing Subjective Norm Direct 1
HCP Subjective Norm Direct 1
Self-testing Self-efficacy 1 (easy)
HCP Self-efficacy 1 (easy)
Self-testing Response Costs 2 (support)
HCP Response Costs 2 (support)
Self-testing Attitude Indirect (embarrassing)
HCP Attitude Indirect (embarrassing
Attitude Indirect, importance rating
Self-testing Subjective Norm Direct 2
HCP Subjective Norm Direct 2
Self-testing Self-efficacy 2 (confident)
HCP Self-efficacy 2 (confident)
Self-testing Inteion
HCP Intention
Intention Choice
Age
Ethnicity
Education (years from 5)
Used other self-test kits
Entered type of kit used?
No. sexual partners over lifetime
No. sexual partners last 12 mths
Preferred gender of partner
Condom use, new partner
Condom use, long-standing relationship
Comments about testing
Can contact for follow-up?
Would like results summary?
Email address?