National Survey on Structural Contributors to HIV Vulnerability Among Black Gay, Bisexual and Same-Gender Loving Men

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1. Gender: (Required.)

Male

Transgender

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2. Race/Ethnicity: (Required.)

African American

Mixed

Other (please specify)

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3. Age range: (Required.)

under 18

18-25

26-35

36-45

46-55

56-above

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4. Sexual orientation: (Required.)

Gay

Bisexual

Same-Gender Loving

Other (please specify)

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5. HIV status: (Required.)

HIV-Positive

HIV-Negative

Don't Know

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6. Location:

State:

ZIP:

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7. What is the highest grade or level of school that you have completed? (Required.)

8th grade or less

Some high school, but did not graduate

High school graduate or GED

Some college or 2-year degree

4-year college graduate

More than 4-year college degree

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8. Are you currently employed? (Please check all that apply) (Required.)

Full-time

Part-time

Permanent

Temporary

Seasonal

Student

Other

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9. What is your estimated annual income? (Required.)

Under $15,000

$15,001 - $30,000

$30,001 - $45,000

Over $45,000

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10. What is your current housing situation? (Required.)

Rent

Own

Stay With Someone

Receive Government Assistance (Section 8, HOPWA, etc.)

Shelter

Between Homes

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11. Do you currently have health insurance coverage? (Required.)

Yes, Employer-Based

Yes, Privately Purchased

Yes, Medicaid

Yes, Medicare

Other (please specify)

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* 1. Gender: (Required.)

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* 2. Race/Ethnicity: (Required.)

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* 3. Age range: (Required.)

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* 4. Sexual orientation: (Required.)

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* 5. HIV status: (Required.)

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* 6. Location:

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* 7. What is the highest grade or level of school that you have completed? (Required.)

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* 8. Are you currently employed? (Please check all that apply) (Required.)

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* 9. What is your estimated annual income? (Required.)

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* 10. What is your current housing situation? (Required.)

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* 11. Do you currently have health insurance coverage? (Required.)

1. Gender: (Required.)

2. Race/Ethnicity: (Required.)

3. Age range: (Required.)

4. Sexual orientation: (Required.)

5. HIV status: (Required.)

6. Location:

7. What is the highest grade or level of school that you have completed? (Required.)

8. Are you currently employed? (Please check all that apply) (Required.)

9. What is your estimated annual income? (Required.)

10. What is your current housing situation? (Required.)

11. Do you currently have health insurance coverage? (Required.)