Syringe Exchange Services Survey
What is the name of your exchange?
Your answer
Give us a one to two sentence description of your exchange.
Your answer
Do you have a mission statement? If so, please write in the space below.
Your answer
If someone has questions, how should they contact you?
Your answer
When are you open?
Your answer
What's your address?
Your answer
What should I look for? e.g., is there a sign? Are you in a church? Are you by any recognizable landmarks?
Your answer
Where can I park?
Your answer
How accessible are you by public transportation?
Your answer
Which of these supplies do you usually have?
Required
What gauges of syringes/barrels/needles do you offer?
Your answer
Is there a limit on the number of syringes an individual can pick up?
Your answer
What services do you provide besides syringe exchange? (e.g., HIV Testing, Counseling, etc.)
Your answer
Are there age restrictions for who can come to the exchange?
Your answer
Can you bring your children along to the exchange?
Your answer
What else do you want people to know about your program?
Your answer
How likely are you to recommend Haystak to your clients?
Not likely
Very Likely
What else would you like to see on Haystak?
Your answer
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