DENIM Collection Survey Question Title * 1. First Name Question Title * 2. Last Name Question Title * 3. Services Requested/Received (select all that apply) Food Pantry Shower Laundry Clothing Closet Case Management Sexual Health Screening (HIV/STI) PrEP Services HIV primary Care Harm Reduction Question Title * 4. Select Client Type New Client Returning Client Question Title * 5. Date Service Requested/Received Date Date Question Title * 6. Please provide your cell phone number so we can contact you. Question Title * 7. What is your email address? Question Title * 8. What is your age range? 13 - 17 years old 18 - 25 years old 26 - 35 years old 36 - 45 years old 46 - 55 years old 56 + years old Question Title * 9. What is your race? Black/African American White/Caucasian Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Mixed Race Other (please specify) Question Title * 10. What gender do you consider yourself to be? Male Female Transgender (Male to Female) Transgender (Female to Male) Gender Non-conforming/Nonbinary Other (please specify) Question Title * 11. What is your sexual orientation? Gay or homosexual Bisexual Straight or heterosexual Queer Questioning Other (please specify) Question Title * 12. Ethnicity Hispanic Not Hispanic Question Title * 13. Employment Status Working full-time Working part-time or occasionally Student Unemployed Unable to work (disabled) Retired Question Title * 14. Do you receive SNAP benefits? Yes No Question Title * 15. Total size of household Question Title * 16. Total number of children Question Title * 17. Additional services needed (list services so the Coordinator can follow up and support you with linkage) Question Title * 18. How likely are you to recommend the DENIM Pantry to a friend, colleague, family or partners? Very likely Likely Unlikely Very unlikely Done