2022 Area 15 Care Needs Survey

As a person living with HIV (PLWH) you have the power and responsibility to shape your care. This is the chance to tell the Department of Health (DOH) what services you need. It will help your DOH and your local planning group decide how to fund and improve services in your area.

This survey is ANONYMOUS and can take less than 10-15 minutes to complete.

Question Title

* 1. What is your gender?

Woman/Girl/Female

Man/Boy/Male

Transgender Woman or Transfeminine

Transgender Man or Transmasculine

Gender Non-Binary

Gender Non-Conforming or Gender Fluid

Prefer not to answer

Not listed, please specify

Question Title

* 2. What is your race? (Select all that apply)

White/Caucasian

Black or African American

Asian

American Indian or Alaskan Native

Native Hawaiian or Pacific Islander

Mixed/more than one race

Prefer not to answer

Other (please specify)

Question Title

* 3. What is your ethnicity? (Select all that apply)

Hispanic/Latina/Latino/Latinx

Haitian

None of the above

I don't know

Prefer not to answer

Question Title

* 4. How old are you?

18-24

25-34

35-44

45-54

55-64

65+

Question Title

* 5. Through which mode of exposure did you get HIV?

Heterosexual sexual contact

Injection Drug Use (IDU)

Male-to-Male Sexual Contact (MMSC)

From my mother/from birth

Unknown

Other (please specify)

Question Title

* 6. What kind of health insurance or health care coverage do you currently have? (Select all that apply)

A health plan purchased through an employer (or through a family member’s job)

A private health plan purchased through an
exchange (i.e., Affordable Care Act -Obamacare)

Medicaid

Medicare

Tricare (Veterans)

Other medical assistance program (e.g., Ryan White)

I don’t currently have any health insurance

I prefer not to answer

I don’t know

Not listed, please specify

Question Title

* 7. What is your current source of income? (Select all that apply)

Working full-time job

Working part-time job

Self employed

Working off and on

Not working, please provide reason

Question Title

* 8. What was your household total or individual income in 2020? (approximately, before taxes)

Less than $15,000

$15,000-$30,000

$30,001-$50,000

$50,001-$100,000

More than $100,000

Question Title

* 8a. How many dependents does your income support? Please state the number of dependents.

Question Title

* 9. What zip code do you live in?

Question Title

* 10. How often did you receive HIV-related medical care during the past 12 months?

None/Zero

One time

Two times

Three times

Four or more times