* 1. Email

* 2. First Name

* 3. Last Name

* 4. Postal Code

* 5. Phone

* 7. Sex Assigned at Birth

* 9. Are you of Hispanic, Latino, or Spanish Origin?

* 12. What is your HIV status?

* 13. Have you been personally affected by Indiana laws that criminalize HIV?

* 14. Do you currently work in a position that provides services or care to people living with HIV in Indiana?  

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