At-Home HIV/STI Testing Kit Sign Up

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Available for only individuals living in Arkansas state.

Terminology You Should Know

In order to serve all of our clients, Ozark Pride Staff/Volunteers may use the following terminology:
• Cisgender (Cis) - When your gender aligns with your assigned gender at birth
• Transgender (Trans) - When your gender differs from your assigned gender at birth
• Gender Non-binary (GNB) - When your gender differs from the binary genders

I understand Ozark Pride staff will use terms like Cisgender, Nonbinary, and Gender nonconforming

First Name *

Date of Birth *

Please remove the default year and put in the birth year.

YYYY

Pronouns *

Please know that due to the limitations of Google Forms we are unable to use our standard "My pronouns are " option. Google makes us use the other "option" to capture this information.

They, Them, Theirs

Ze, Hir, Hirs

She, Her, Hers

He, Him, His

I don't have a set of preferred pronouns

Other:

Are you capable of receiving mail? *

Yes

Maybe

Required

Mailing Street Address

City

Zip Code

Phone Number *

Email Address *

Do you prefer either Email or Phone for contact? *

Phone

Preferred Contact Time *

Please click all that apply

Morning

Afternoon

Evening

Are you comfortable with blood? *

Yes

Yes, with support

Are you able to take your own blood sample? *

Yes

Last time you tested for HIV

Leave blank if you've never tested for HIV. If you don't remember the exact date, estimate the date to the best of your ability.

YYYY

Are you concerned about a possible HIV exposure? *

Yes

If yes, when did this possible exposure happen?

YYYY

Submit

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