1. Northern Nevada Outreach Team

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* 1. Gender

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* 2. Age

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* 3. Race/Ethnicity:

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* 4. What is your relationship status?

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* 5. What is the highest grade of school or year of college you have completed? (Check One)

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* 6. Which of the following best describes where you live right now? (CHECK ONE ONLY)

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* 7. What do you consider your sexual orientation?

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* 8. During the past 12 months who were your sexual partners?

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* 9. How many sexual partners (vaginal, oral, anal) have you had in the past 12 months?

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* 10. Have you done any of the following in the past 12 months? (CHECK ALL THAT APPLY)

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* 11. How often have you used condoms in the past 12 months when you had sex? (vaginal, oral, anal)

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* 12. What may prevent you from using condoms? (check all that apply)

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* 13. Have you injected drugs in the past 12 months ?

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* 14. If Yes to the question above, have you done any of the following in the past 12 months? (CHECK ALL THAT APPLY)

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* 15. Have you ever been tested for HIV? (even if you didn't get the results. If no skip to question 17)

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* 16. When was the last time you were tested for HIV?

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* 17. If you haven't been tested for HIV, why? (check all that apply)

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* 18. If you had a question about HIV/AIDS, where would you go for information?
CHECK ALL THAT APPLY)

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* 19. For the following statements, please mark how you agree or disagree with the statement

  Strongly Agree Somewhat Agree Somewhat Disagree Strongly Disagree
Medical care can help a person live longer and stay healthier if he/she has HIV/AIDS
My sexual partners and/or needle sharing partners are genuinely concerned with whether I have had an HIV/AIDS test and what the results were
I see HIV/AIDS as a manageable/treatable disease and am not as concerned about getting it
Taking HIV/AIDS drugs decreases the chances that someone with HIV/AIDS will infect their partners
Oral sex without a condom is safe if there is no ejaculation (cum)
Anal sex without a condom is safe if there is no ejaculation (cum)
Sometimes I do not use condoms because they require too much effort
I feel that people who got infected with HIV/AIDS through sex or drug use got what they deserve
I feel comfortable being around someone with HIV/AIDS
I feel that there is enough messaging/education about HIV/AIDS in my community
I would date someone who is infected with HIV/AIDS
HIV/AIDS does not affect my life
I am not concerned about getting HIV/AIDS……
I know where to get an HIV/AIDS test…………

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* 20. Thank you for you time! Please add any additional comments here.

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