Conversation Contact Form Question Title * Which program is being reported? POL D-up Question Title * My Name Question Title * Today's Date Date Submitted Date Contact 1 Question Title * Date of Contact Date Date Question Title * Contact Information Name Place of Contact Age Contact Phone Number Question Title * Summary of Conversation Question Title * Is this person a Black Man Who has sex with other men? Yes No Don't Know Contact 2 Question Title * Date of Contact Date Date Question Title * Contact Information Name Place of Contact Age Contact Phone Number Question Title * Summary of Conversation Question Title * Is this person a Black Man Who has sex with other men? Yes No Don't Know Contact 3 Question Title * Date of Contact Date Date Question Title * Contact Information Name Place of Contact Age Contact Phone Number Question Title * Summary of Conversation Question Title * Is this person a Black Man Who has sex with other men? Yes No Don't Know Contact 4 Question Title * Date of Contact Date Date Question Title * Contact Information Name Place of Contact Age Contact Phone Number Question Title * Summary of Conversation Question Title * Is this person a Black Man Who has sex with other men? Yes No Don't Know Contact 5 Question Title * Date of Contact Date Date Question Title * Contact Information Name Place of Contact Age Contact Phone Number Question Title * Summary of Conversation Question Title * Is this person a Black Man Who has sex with other men? Yes No Don't Know Contact 6 Question Title * Date of Contact Date Date Question Title * Contact Information Name Place of Contact Age Contact Phone Number Question Title * Summary of Conversation Question Title * Is this person a Black Man Who has sex with other men? Yes No Don't Know Contact 7 Question Title * Date of Contact Date Date Question Title * Contact Information Name Place of Contact Age Contact Phone Number Question Title * Summary of Conversation Question Title * Is this person a Black Man Who has sex with other men? Yes No Don't Know Contact 8 Question Title * Date of Contact Date Date Question Title * Contact Information Name Place of Contact Age Contact Phone Number Question Title * Summary of Conversation Question Title * Is this person a Black Man Who has sex with other men? Yes No Don't Know Contact 9 Question Title * Date of Contact Date Date Question Title * Contact Information Name Place of Contact Age Contact Phone Number Question Title * Summary of Conversation Question Title * Is this person a Black Man Who has sex with other men? Yes No Don't Know Contact 10 Question Title * Date of Contact Date Date Question Title * Contact Information Name Place of Contact Age Contact Phone Number Question Title * Summary of Conversation Question Title * Is this person a Black Man Who has sex with other men? Yes No Don't Know Page1 / 1 100% of survey complete. Submit Conversations