A research proposal template on any microbiological topic, Summaries of Microbiology

Download A research proposal template on any microbiological topic and more Summaries Microbiology in PDF only on Docsity! Sample ID________ Date: ______________ UNIVERSITY OF PORT HARCOURT DEPARTMENT OF MICROBIOLOGY VIRUS RESEARCH UNIT A Questionnaire HIV-1 Genetic Diversity, Coreceptor Usage and Drug Resistance Mutations among ART-Naïve HIV- Infected Individuals in the South-South Region, Nigeria. Fill or tick (√ ) in the box opposite the option that applies to you. SECTION A: SOCIO-DEMOGRAPHIC PROFILE 1. Age __________ Sex a) Female _______ b) Male _______ Place of Residence _______________ 2. Religion a) Christianity ___ b) Islam ___ c) Traditional ___ d) Others (please specify) _________ 3. Occupation: a) Trader ____ b) Teacher ____ c) Civil Servant ____ d) Business ___ e) Artisan ____ f) Farmer ____ g) Student ____ h) Unemployed ___ i) Others (specify) _________________ 4. Marital status: a) Single _____ b) Married _____ c) Separated/Divorced____ d) Widowed ____ a) If married; Marriage type: a) Monogamous______ b) Polygamous______ b) If married; Occupation of spouse _____________ HIV Status of spouse a) Positive ____ b) Negative ____ a) Educational level: a) Primary __ b) Secondary __ c) Tertiary __ d) None__ e) Others (specify) _________ SECTION B: CLINICAL HISTORY 5. When did you find out you were infected with HIV? (Month/Year) ________ 6. Where were you diagnosed? ___________________ 7. Which of the WHO stage of HIV do you belong to? a) I ___ b) II ___ c) III ___ d) IV ___ e) Not sure ___ 8. Are you on ART/drugs (Antiretroviral therapy)? a) YES_____ b) NO_____ a) If YES, when did you start taking drugs: ____________________________________________ b) What are the names of drugs you are taking now? ____________________________________ c) Which ones did you use before? __________________________________________________ 9. Were you referred to this centre? a) Yes _______ b) No _______ a) If Yes, have you been placed on drug before coming to this centre? a) Yes ____ b) No ____ b) What are the names of the drugs? ______________________________________________ c) Do you have any other infection aside HIV? a) YES__ b) NO__ If YES, specify? ________________ SECTION C: RISK FACTORS 10. Please indicate from the list below if you have undergone/have any of the following. Check/Tick all that apply as appropriate. S/N List Yes No If Yes, When (year) a. Tribal marks/Scarification/Tattoo on your body/ Body piercing b. Received blood transfusion c. Received surgical procedure in health facility d. Local circumcision e. Local ‗belubelu‘- uvulectomy or/and tonsillectomy f. Delivery of child at home g. Dental procedure in health facility h. Dental procedure outside health facility i. Blood oaths j. Intravenous drug user (IDU) k. Living with and Sharing facilities and materials with IDU l. Sharing of sharp objects m. Needle stick injury n. Exposure to blood, body fluids or tissues o. On dialysis treatment p. Sharing of toothbrush/chewing q. Local hair shaving r. Local manicure/pedicure s. Others (Please specify) a. Have you had a sexual partner who was/is not your spouse(s) or your regular partner within the last 6 months? a) YES__ b) NO___ c) Don’t Remember____ If yes, how many were they? ___________________ b. How regularly do you use condom when having sex with someone who isn’t your spouse or regular partner? a) Always _____ b) Sometimes _____ c) Not at all _____ Laboratory Information (to be completed by the researcher) CD4 count ____________________________ Viral Load ____________________________ 1