Get Tested
Thank you for your interest in getting an HIV Home test kit from Samaritan Ministry.
We need to collect some basic information below to make sure you qualify for the free HIV test.
All of your information is kept confidential. All sections are required.
* Required
Email address
*
Your email
Name (first and last)
*
Your answer
Mailing Address (street)
*
Your answer
Mailing Address (City, State, ZIP)
*
Your answer
Gender
*
Female
Male
Prefer not to say
Other:
Required
What is your age?
*
17 or younger
18 - 30
31 - 49
50+
Required
Do you identify as Hispanic, Latinx, or Spanish?
*
Yes
No
Prefer not to say
Required
How long has it been since your last HIV test?
*
Less than 1 month
1 - 6 months
7 - 12 months
More than 12 months
I have never been tested.
Required
What is your race? For mixed race, select all that apply.
*
American Indian
Asisan
Native Hawaiian or Pacific Islander
White
Alaskan Native
Black or African American
North African or Middle Eastern
Other
Required
What best describes your sexual orientation? (select one)
*
Gay
Lesbian
Questioning
Bisexual
Heterosexual or Straight
Prefer not to say
Other
Required
Which best describes your use of Pre-Exposure Prophylaxis (PrEP)? To learn more about PrEP, check out
https://getpreptn.com/
*
I take PrEP once a day as prescribed.
I take on-demand PrEP around sexual activity
I take PrEP sometimes.
I have never taken PrEP.
I do not know about PrEP.
I was taking PrEP, but am not now.
Required
What might have put you at risk for HIV? (select all that apply)
Anal sex with a male
Vaginal or anal sex with a transgender person
Injection drug use
Vaginal or anal sex with a femal
Vaginal or anal sex without a condom
Something else
How would you prefer to receive your At-Home Test Kit?
*
Mail At-Home Test Kit
E-mail At-Home Test Kit voucher (redeemable at Belew Pharmacies in Knoxville, Tennessee)
Required
How did you learn about Samaritan Ministry's home testing service?
Your answer
Thank you for completing the Get Tested questionnaire. We will follow up with a confirmation email.
http://www.samaritancentral.org
Send me a copy of my responses.
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