Education Hep C Assessment Online
Informing our community about Hep C and HIV
Sign in to Google to save your progress. Learn more
Email *
Follow Us!
FB: @peasmemphis2009
IG: @partnershiptoendaidsstatus
TikTok: @peasinc
Twitter: @to_aids
Name *
Thank you for Attending our Hep C Session
Preferred Gender *
Birth date *
Preferred Race *
Phone Number
Relationship Status
Clear selection
Do you have health insurance
Clear selection
Have you ever been tested for Hepatitis C or any other STD's? *
Would you like to be tested for Hepatitis C?
Clear selection
Please review the following list of risk factors and check all that apply: *
Please rate your facilitator *
Hepatitis is rare? *
The Liver is the body part affected by hepatitis
Clear selection
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?
Clear selection
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 *
List at least one thing you are taking from this session. *
How likely are you to use this  information learned *
Not likely
More Likely
How often do you frequent PEAS, Inc. *
Thank you! is there anything you need from PEAS, Inc? *
Date *
Electronic Signature *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy