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Self-Test Kit Risk Assessment
Thank you for your interest in the Self-test HIV kits. We will need a small amount of information for statistical purposes:
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* Gibt eine erforderliche Frage an
Age (please choose one):
*
18 or younger
19 to 24
25 to 45
46 or older
Assigned Sex at Birth
*
Male
Female
Prefer not to say
Sonstiges:
Current Gender Identity
*
Male
Female
Nonbinary
Genderqueer
Trans-Masc
Trans-Fem
Prefer not to answer
Sonstiges:
Racial Identity (check all that apply)
Indigenous/First Nations
African American/Black
Afrolatin(a/o/x)
Asian
Caribbean
Caucasin/White
Pacific Islander
Mediterranean/Midde Eastern/Arabic
Sout Asian Islander
Multiracial
Prefer not to answer
Unknown
Sonstiges:
Do you identify as Hispanic or Latin(o/a/x)
*
Yes
No
Prefer not to answer
Risk Factors (check all that apply)
*
Unprotected sex with males
Unprotected sex with females
Shared needle(s) for substance use
Shared tattoo equipment
Accidental or unknown needle stick
Partner is postive or tested positive
Unknown blood exposure
None of the above
Current Sexual Orientation (Select all that apply)
*
Heterosexual
Homosexual/Gay/Lesbain
Bisexual
Pansexual
Demisexual
Asexual Spectrum
Prefer not to answer
Unknown
Other
Would you like for a test kit to be mailed to you?
*
Yes
No
If yes, enter your name.
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If yes, enter your address.
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Current Zip Code
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Dieses Formular wurde bei AIDS Ministries/AIDS Assist of North Indiana erstellt.
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