HIV Self Testing Kits Please fill out all questions below. Question Title * 1. Please write your first name. Question Title * 2. Please write your last name. Question Title * 3. Please provide your phone number Question Title * 4. Please enter your email address. Question Title * 5. What is your age? Question Title * 6. Select your sex at birth: Male Female Question Title * 7. What sex do you identify as now? Male Female Other (please specify) Question Title * 8. What is your Sexual Orientation? Lesbian Gay Bisexual Transgender Straight/Heterosexual Other (please specify) Question Title * 9. What is your ethnicity? (Please select all that apply.) American Indian or Alaskan Native Asian or Pacific Islander Black or African American White/Caucasian Hispanic or Latino Unknown/Not reported Other (please specify) Question Title * 10. Would you like to pick up test kit or have it mailed? Mail to home address Pick up at nearest Health Department Question Title * 11. Please provide your mailing address ( ONLY FOR KITS MAILED TO HOME) Street City State Zip Code Question Title * 12. Choose your nearest Health Department ( ONLY FOR PICK-UP): Bleckley County Health Dept. Dodge County Health Dept. Johnson County Health Dept. Laurens County Health Dept. Montgomery County Health Dept. Pulaski County Health Dept. Telfair County Health Dept. Treutlen County Health Dept. Wheeler County Health Dept. Wilcox County Health Dept. Question Title * 13. How did you hear about the HIV Self Test Kit Program? Done