* 1. What type of health care insurance do you use to pay for your doctor or hospital
bills? (Please check one. If you have more than one type of insurance, please choose
your primary coverage.)

* 2. If you need health care, where do you usually go to get it? (Please check one. If you
go to more than one of these, please choose the one you go to most often.)

* 3. How much does each of the following make it hard for you to receive the health care, services or
opportunities you need? (Please mark one answer for each item.)

  No problem at all A slight problem A significant problem A major problem
Long distances to LGBT-sensitive medical facilities
Health care providers who aren't comfortable or familiar with LGBT people
Health care providers who refuse to provide services to LGBT people
Fear that if medical personnel find out I am LGBT, they will treat me differently
Health professionals inadequately trained or incompetent to treat LGBT people
Not enough mental health counselors who can help me with psychological issues
Not enough support groups for LGBT people
Community fear or dislike of LGBT people
My personal financial resources
Don’t have adequate and affordable housing
Don’t have transportation to get to the services I need

* 4. Have you ever experienced any of the following that you have reason to believe was motivated by
homophobia (fear or dislike of lesbians, gay men or bisexual people) or transphobia (fear or dislike of
transgender people)?
If yes, did you report it to the police? (After each item on the list, please check Yes or No to show whether
or not this has happened to you and whether or not you reported it to the authorities.)

  Yes No
Verbal harassment
Did you report it?
Neglect by a caregiver
Did you report it?
Taken advantage of financially or blackmailed
Did you report it?
Physical assault
Did you report it?
Property damage or arson
Did you report it?
Sexual assault
Did you report it?
Physical assault requiring medical attention
Did you report it?
Threat of violence
Did you report it?
Threat of death
Did you report it?
Domestic violence/Dating violence
Did you report it?
Did you report it?

* 5. I feel safe in my community.

* 6. Last year, how many times did you go to events at an LGBT center or other place that
is specifically for LGBT people?

* 7. How often have you used health or human services that were specifically targeted to
LGBT people? Human services include any professional services that improve your
health or well-being.

* 8. If there were a list of health and human service providers who were certified as being
trained in, knowledgeable about, and sensitive to LGBT issues, how likely is it that you
would use this list to choose a provider?

* 9. Over the past month, how often have you been bothered by any of the following problems?

  Not at all Once a week Half of the days More than half the days Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Feeling anxious or nervous
Feeling lonely or isolated
Suicidal thoughts
Lack of companionship
Lack of social opportunities

* 10. What is your current gender identity? (Please check all that apply)

* 11. What was the sex on your original birth certificate?

* 12. How do you identify your sexual orientation (please check all that apply).

* 13. What is your racial and/or ethnic identity? (Please check all that apply)

* 14. What is your current age?

* 15. How many children live with you?

* 16. What is your current relationship status?

* 17. What best describes your household income last year?

* 18. How would you describe your income?

* 19. What is your employment and educational status?

* 20. What is your zip code?

* 21. What county do you reside in?

* 22. How would you describe where you live?

* 23. Have you ever been homeless?

* 24. How much do you agree or disagree with each of the following statements about being "out" as a lesbian, gay, bisexual, and/or transgender person?

  Strongly agree Agree Neither agree, nor disagree Disagree Strongly disagree
I am out to my family
I am out to my friends
I am out at my school
I am out at my work
I am out to my healthcare providers

* 25. People can tell that I am LGTB even if I don't tell them

* 26. Compared to others of my gender, I appear

* 27. Which of the following LGTB-specific services would you be most interested in?

* 28. Please tell us what you think are the most important needs for LGTB people in Southeastern North Carolina that are not currently being met?

* 29. Please give us your preferred contact information, if you would like to be informed of services and resources for the LGTB communities.