* 1. Please provide the first and third letters of your first name and the first and third letters of your last name.  As an example, it your name was John Doe, you would enter JH  and then DE.  Secondly, enter your date of birth in the two digit MONTH/DAY/YEAR format.  As an example, if you were born on December 25, 1990, you would enter 12/25/90.

* 2. What is your Zip Code?  If not known, what county do you live in?

* 3. What year were you diagnosed with HIV?  If unknown, please note in comment box.

* 4. In what city and state were you FIRST diagnosed with HIV?

* 5. What year were you diagnosed with AIDS?  If you have been diagnosed with AIDS, what city and state were you FIRST diagnosed with AIDS?

* 6. Where did you first learn about your positive diagnosis?

* 7. Do you know how you may have acquired HIV/AIDS?  (Please check all that may apply)

* 8. Do you currently have health insurance?

* 9. When was the last time you saw a doctor to treat your HIV?

* 10. What clinic/doctor's office do you go to for your HIV treatment?

* 11. When was the last time you had a CD4 (T-Cell) Count?

* 12. When was the last time you had a Viral Load test?

* 13. Are you currently taking ART (HIV) medications?

* 14. Are you currently being treated for a mental illness?

* 15. Are you currently being treated for substance abuse?

* 16. Have you ever been diagnosed with or treated for sexually transmitted infections (STIs, including syphilis, gonorrhea or chlamydia)?

* 17. Are you now or have you ever been homeless?

* 18. Do you currently

* 19. How much is your monthly rent or mortgage?

* 20. Are you currently employed?

* 21. What is your approximate yearly income?

* 22. What is your highest level of education?

* 23. What is your sexual orientation?

* 24. Have you been in jail or prison in the past six (6) months?

* 25. Are you?

* 26. Do you consider yourself?

* 27. Were you born in the United States?

* 28. Is a language other than English most commonly spoken in your home?

* 29. Need:  As a person living with HIV/AIDS, what are the five (5) most important needs for you to get or stay healthy?  Rank the top five (greatest need = no. 1, etc.)

* 30. Need:  As a person living with HIV/AIDS, what are the five (5) most important needs for you to get or stay healthy?  Rank the top five (greatest need = no. 1, etc.)

* 31. List any services that you need for HIV care that are difficult to access (hard to get).

* 32. Why are these services hard to get?

* 33. List any services that you need for HIV care that you cannot get.

* 34. Why can't you get these services?

* 35. Thank you for your time in completing this survey.  Your confidential responses will be valuable information for the Charlotte TGA Advisory Council. 

If you want to receive a $10 food voucher, please let us know where to mail it.  Your contact information will remain confidential. Please allow 4 weeks for receipt of food voucher.  Only ONE voucher per eligible Ryan White client.

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