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HMM Individual
*
1.
Email
(Required.)
*
2.
First Name
(Required.)
*
3.
Last Name
(Required.)
*
4.
Postal Code Where you Live
(Required.)
5.
Phone
6.
Age
Less than 18
18-29
30-39
40-49
50-59
60+
Prefer not to answer
7.
Gender Identity
Female
Male
Trans woman
Trans man
Gender queer
Prefer not to answer
Other (Please specifiy)
8.
What is your sexual orientation?
Gay
Lesbian
Bi
Straight
Prefer not to answer
Other (please specify)
9.
Are you of Hispanic, Latino, or Spanish Origin?
Yes
No
I prefer not to answer
10.
What is your race?
White
Black
Asian or Pacific Islander
Native American
Bi or multi racial
Prefer not to answer
Other (please specify)
11.
What is your HIV status?
Positive
Negative
Unsure
I prefer not to answer
12.
Have you ever been directly affected by Indiana laws that criminalize HIV?
Yes
No
I prefer not to answer
13.
What is your main place of employment, if any, and position there? (If not working, write N/A).
*
14.
Professional Credentials if any
(Required.)
MD
PhD
MPH
JD
MA/MS
DPH
MSN
Other (please specify)