Informed Consent Form
Dear respondent,
I am carrying out a study to assess knowledge, sources and prevention of sexually transmitted
infections among students.
I am requesting you participate in this study by filling out this questionnaire as honestly as
possible. Participation is optional and you have a right to withdraw from the study at any point
without penalty. Confidentiality of your information provided is highly guaranteed, and it shall
be used for academic purposes only. In case you have any question or need clarification, feel free
to ask. Kindly show your acceptance and willingness to participate in the study by signing the
space below. Do not write your name.
Participant
I have read and understood this consent and I am voluntarily accepting to participate in this
study.
Participant’s signature / initials……………..
Date…………………….
Socio-demographic characteristics of the respondents
This section will constitute information about you. Tick appropriately
a) Age in years
17-23 { }
24-27 { }
28-30 { }
b) Sex
Male ( )
Female ( )
c) Year of study
Year 1 ( )
Year 2 ( )
Year 3 ( )
d) Religious Affiliation
Christian. ( )
Muslim. ( )
Hindu. ( )
Others (specify)
II. Awareness on sexually transmitted infections/diseases
I. How do people contract sexually transmitted infections? Write either yes/no/don’t
know.
From needles and syringes------
Blood and blood products-------
Sharing the same blade with an infected person-------
Unprotected sexual intercourse-------
From mother to child--------
From sharing the same toilet with an infected person----
Exposure to cough and sneeze----------
2. What are the common complaints in people with STI? Write either yes/no/don’t know in front
of options given.
a) Weight loss--------
b) Burning pain when passing urine--------
c) Discharge from genital area-------
D) Wound/sore in the genital area---------
e) Body rash, swelling or boil around genital areas--------
e) Other (specify)
3. Does having another STI place a person at a greater risk of infection if they are exposed to
HIV?
Yes ( )
No ( )
Don’t know ( )
4. Which is the most common STI caused by bacteria?
Gonorrhoea ( )
Syphilis ( )
Chlamydia ( )
Genital warts ( )
5. Which major organ can be affected by untreated syphilis?
Liver ( )
Brain ( )
Heart ( )
1and 2 above ( )
6. Can STIs be transmitted through oral or anal sex?
Yes ( )
No ( )
7. There are medicine to cure HIV Rephrase this question
True ( )
False ( )
Don’t know ( )
8. There is cure for gonorrhoea.
True ( )
False ( )
Don’t know ( )
9. The same virus causes all sexually transmitted infections.
True ( )
False ( )
Don’t know ( )
II) Sources of information on sexually transmitted infections
Tick appropriately.
What are your sources of information?
TV/radio ( )
Newspapers/ magazine ( )
Public talks/seminars ( )
Billboards/posters ( )
Hospital/health workers ( )
Teachers ( )
Friends/relatives ( )
Parents ( )
Others ( )
How often do parents discuss with you about STIs?
Frequently ( )
Once a month ( )
Once a year ( )
Never ( )
IV) Prevention of sexually transmitted infections
Tick appropriately.
a) Condoms make sex completely safe
True ( )
False ( )
Don’t know ( )
b) Does using condom only some of the times offer any protection for STI?
Yes ( )
No ( )
Don’t know ( )
c) To lower your risk of getting STI,
1. Use Condom ( )
2. As a young person delay having sexual relations as long as possible ( )
3. Avoid multiple sex partners ( )
4. All of the above ( )
5. Others ( )
c) Is abstinence 100% effective in preventing someone from getting an STI?
Yes ( )
No ( )
Don’t know ( )
c) Is there a pill to prevent STIs?
Yes ( )
No ( )
Don’t know ( ) S
d) Have you ever been tested for STI or HIV
Yes ( )
No ( )
If No why?..................
