JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Education Hep C Assessment Online
Informing our community about Hep C and HIV
Sign in to Google
to save your progress.
Learn more
* Required
Email
*
Your email
Follow Us!
www.partnershiptoendaidsstatus.com
FB: @peasmemphis2009
IG: @partnershiptoendaidsstatus
TikTok: @peasinc
Twitter: @to_aids
Name
*
Your answer
Thank you for Attending our Hep C Session
Preferred Gender
*
Female
Male
M to F
F to M
Prefer not to say
Other:
Birth date
*
MM
/
DD
/
YYYY
Preferred Race
*
Black
White
Hispanic
Alaskan
Native American
Other:
Address
Your answer
Phone Number
Your answer
Relationship Status
Married
Single
Divorce
Widowed
Separated
Other:
Clear selection
Do you have health insurance
Yes
No
Clear selection
Have you ever been tested for Hepatitis C or any other STD's?
*
Yes
No
Maybe
Would you like to be tested for Hepatitis C?
Yes
No
Maybe
Clear selection
Please review the following list of risk factors and check all that apply:
*
Blood Transfusion before 1992
Long Term Dialysis
Injectable drug use even once
History of drug use
Tattoos or body piercings
Close contact with indidviduals with Hepatitis C
Sex for drugs or money
History of high-risk sex
Incarcerated longer than 6 months
HIV +
Fist fighting or combat experience
Other:
Required
Please rate your facilitator
*
Bad
1
2
3
4
5
Excellent
Hepatitis is rare?
*
Yes
No
Maybe
The Liver is the body part affected by hepatitis
Yes
No
Maybe
Clear selection
Hepatitis C virus causes severe liver disease in everyone who has it?
*
True
False
You can get Hepatitis C if you inject drugs>
*
Yes
No
Maybe
You can have Hepatitis C and not feel sick?
True
False
Clear selection
Hepatitis C is spread through dirty food and water?
*
True
False
I can protect myself from getting Hepatitis C?
*
True
False
Please rate the quality of how information was presented
*
Excellent
Very good
Good
Fair
Poor
Please rate the quality of the staff
*
Excellent
Good
Fair
Poor
Please rate the quality of your time spent
*
Bad
1
2
3
4
5
Excellent
List at least one thing you are taking from this session.
*
Your answer
How likely are you to use this information learned
*
Not likely
1
2
3
4
5
More Likely
How often do you frequent PEAS, Inc.
*
1-2 times
3-5 times
Once a month
Other:
Thank you! is there anything you need from PEAS, Inc?
*
Your answer
Date
*
MM
/
DD
/
YYYY
Electronic Signature
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
