Education Hep C Assessment Online
Informing our community about Hep C and HIV
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Email *
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Name *
Thank you for Attending our Hep C Session
Preferred Gender *
Birth date *
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Preferred Race *
Address
Phone Number
Relationship Status
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Do you have health insurance
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Have you ever been tested for Hepatitis C or any other STD's? *
Would you like to be tested for Hepatitis C?
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Please review the following list of risk factors and check all that apply: *
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Please rate your facilitator *
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Hepatitis is rare? *
The Liver is the body part affected by hepatitis
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Hepatitis C virus causes severe liver disease in everyone who has it? *
You can get Hepatitis C if you inject drugs> *
You can have Hepatitis C and not feel sick?
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Hepatitis C is spread through dirty food and water? *
I can protect myself from getting Hepatitis C? *
Please rate the quality of how information was presented *
Please rate the quality of the staff *
Please rate the quality of your time spent *
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List at least one thing you are taking from this session. *
How likely are you to use this information learned *
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How often do you frequent PEAS, Inc. *
Thank you! is there anything you need from PEAS, Inc? *
Date *
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Electronic Signature *
A copy of your responses will be emailed to the address you provided.
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