2020 Needs Assessment SC-RW

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* 1. In what year were you born?

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* 2. What is your gender?

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* 3. Do you consider yourself as? (Choose all that apply)

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* 4. Are you Hispanic/Latino(a)?

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* 5. What do you consider as your race? (Choose all that apply)

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* 6. In what country were you born? (ex. United States)

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* 7. Do you feel comfortable speaking English when seeking assistance or services?

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* 8. In what county do you currently live or receive mail? (ex. Richland) 

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* 9. What is your monthly household income for you and any dependents living in your household (people who rely on your income you report to the IRS)?

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* 10. List the number of people including yourself that depend on your monthly household income.

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* 11. How would you describe your current housing situation during the past year?

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* 12. In the past year, have you: (choose all that apply)

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* 13. What is the most likely way you believe you became HIV positive? (Choose all that apply)

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* 14. What was it that prompted you to get tested when you first tested positive for HIV or AIDS? (Check all that apply)

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* 15. In what year were you confirmed or diagnosed as HIV positive?

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* 16. After your first diagnosis, how soon did you receive HIV-related medical care?

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* 17. What reasons best explain why you waited more than one year or never received HIV-related medical care. (Click all that apply)

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* 18. Have you seen a medical provider in the past year for your HIV-related medical care?

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* 19. In the past year, have you missed your medical appointment more than 2 times?

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* 20. If you have not seen a clinician in the past year for HIV-related medical care and/or missed appointments, what are your reasons? (Circle all that apply)

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* 21. Are you taking HIV / AIDS medications at the current time? 

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* 22. If you answered YES to Question 21, please describe how your HIV/AIDS medications are purchased? (Circle all that apply)

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* 23. Has a medical provider given you a viral load test in the last year?

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* 24. Has your medical provider ever told you that your viral load was undetectable?

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* 25. Have you missed one or more doses of your HIV medications in the past month?

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* 26. Please circle all that apply about the pharmacy you use most often:

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* 27. What has been most helpful in finding and connecting to HIV-related medical care? (Click all that apply)

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* 28. In the past year, have you ever been denied medical care for HIV because you could not pay for treatment?

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* 29. In the past year, have you ever been denied primary health care (e.g., health care you needed outside of your HIV care) because you could not pay for the treatment?

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* 30. What would be the best way for you to get information about HIV services?

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* 31. Since you’ve tested positive for HIV, have you ever sought any of the following emotional support services? (Click all that apply)

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* 32. What is the effect of HIV stigma in your life; and how you connect with other people and core/support services?

The next questions will focus on Core Medical Services you received or may have needed but were unable to access in the past year. Please select an appropriate option for each service area.

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* 33. Medical visit for HIV-related medical care.

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* 34. Case manager to coordinate HIV-related medical care and access to other services.

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* 35. Oral health care from a dentist, hygienist, or assistant.

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* 36. Mental health services (psychological or psychiatric treatment and counseling services) provided by a licensed professional in an individual or group setting.

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* 37. Outpatient substance abuse treatment or counseling.

The next questions will focus on Support Services you received or may have needed but were unable to access in the past year. Please select an appropriate option for each service area.

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* 38. Short-term assistance to support emergency, temporary or transitional housing (more than one-month assistance)

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* 39. Transportation assistance to access health care services and/or other support services.

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* 40. Emergency financial assistance to pay for housing costs (rent, etc.).

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* 41. Emergency financial assistance to help pay for essential utilities (gas, electric, water, etc.).

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* 42. Emergency Financial Assistance to receive for food/groceries.

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* 43. Choose up to 3 medical services that are most important to you.

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* 44. Choose up to 3 supportive services that are important to you.

0 of 44 answered
 

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