HIV Self Test Question Title * 1. I agree to provide my test results to Wellness Services. Yes No Question Title * 2. Name: Question Title * 3. Street Address Question Title * 4. County Question Title * 5. Phone number Question Title * 6. Email Question Title * 7. Birthdate Please enter a valid date. Date Question Title * 8. Race/Ethnicity Black Asian Indigenous/First Nations Native Hawaiian or other Pacific Islander Arab/Chaldean Hispanic/Latin White Other (please specify) Question Title * 9. Gender Female Male Transgender Female Transgender Male Non-Binary Not Listed You can enter here if you like Question Title * 10. Have you previously been tested for HIV? Yes No Question Title * 11. Have you ever tested positive for HIV? Yes No Question Title * 12. Do you have Health Insurance? Yes No Question Title * 13. If so, what kind? Question Title * 14. Have you ever heard of PrEP? Yes No Question Title * 15. Are you currently taking PrEP? Yes No Question Title * 16. In the past five years, have you injected drugs or substances? Yes No Question Title * 17. Who do you have sex with? (Check all that apply.) Male Female Transgender Female Transgender Male Non-Binary Not Listed Question Title * 18. Delivery Method of Test Kit Pick-up (someone will call and schedule) Mailed Submit
