AACI's HIV Self-test Kit Form

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In order to raise awareness of HIV, other sexually transmitted infections (STIs), and one's HIV diagnosis status, Asian Americans for Community Involvement (AACI) has partnered with Bay Area Community Health (BACH) and the Centers for Disease Control and Prevention, Department of Health and Human Services (CDC) to distribute HIV Self-Test kits to the public and ensure appropriate linkages to care.

This HIV rapid Self-Test is an FDA-approved antibody test that is relatively easy to use. It will give you your test result within 20 minutes.

To receive an HIV Self-Test Kit, please fill out this survey. An email with follow-up questions will be sent to you at a later date.

Keep in mind that the information you provide to us will be voluntary, confidential, and protected in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Your protected health information will be used for managing your care; fulfilling the contract between AACI, BACH, and the CDC in regard to the Comprehensive High-Impact HIV Prevention Program for Community Based Organizations, HIV Self Testing Program Expansion; and increasing future usage of HIV self-test kits.

If you have any questions, comments, or concerns, please contact Bernadine Dela Rosa via email (Bernadine.delarosa@aaci.org).

Thank you very much for your cooperation.

1. What is your name? *

2. What is your date of birth (mm/dd/yyyy)? *

YYYY

3. What is your address? Please answer this question only if you are interested in HIV self-test kit home delivery.

4. What is your zip code? *

5. What is your phone number? *

6. What is your email address? *

7. Which of the following locations did you receive this HIV Self-Test kit from? *

AACI's Story Road: 749 Story Rd Suite 50, San Jose, CA 95122

AACI's Moorpark: 2400 Moorpark Ave., Suite 300 San Jose, CA 95128

Billy DeFrank LGBTQ+ Community Center: 983 The Alameda, San Jose, CA 95126

Other:

8. What is your gender? *

Male

Female

Genderqueer or genderfluid

Non-Binary

Questioning or unsure

I do not wish to self-identify

Other:

9. Do you identify yourself as trans? *

Yes

10. What is your sexual orientation? *

Straight or heterosexual

Gay or lesbian

Bisexual

Queer, pansexual, and/or questioning

I do not know

I do not wish to self-identify

Other:

11. Are you Hispanic or Latinx? *

Yes

I do not wish to self-identify

12. What is your race? *

Asian

Black or African American

Native American or Alaska Native

Native Hawaiian or Other Pacific Islander

White

Other:

Required

13. Have you been sexually active in the past six months? *

Yes

14. Have you ever been tested for HIV? *

Yes

15. On a scale of 1 to 5 (1 = Poor, 5 = Excellent), what would you rate your knowledge of HIV pre-exposure prophylaxis (PrEP)? *

Poor

Excellent

16. Are you currently on HIV PrEP? *

Yes

17. Have you been tested for syphilis, gonorrhea, or chlamydia in the past six months? *

Yes

18. Would you be interested in receiving more HIV Self-Test kits? *

Yes

19. Do you have any questions, comments, or concerns?

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