Discussions around HIV Stigma

Screening Survey

Thank you for your interest in our upcoming study. Please fill out the following preliminary questions below. Once completed, we will follow up with you shortly after regarding your eligibility in the project and if qualified, to discuss details and scheduling. If you do not qualify, we will email you at the end of the project thanking you for your time and asking if you would be interested in future projects that you may qualify for.

If you have any questions, please contact John at 224-358-9023 or email john@lagripperesearch.com.

Thank you!

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* 1. Please fill out the following contact information:

First Name

Last Name

City

State

ZIP/Postal Code

Email Address

Phone Number

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* 2. We are conducting this survey on behalf of Ipsos, a healthcare market research firm. We would like to ask you a few questions to see if you qualify to participate in a study in which we would offer you an honorarium of $100 for the group and $50 for the homework assignment, in the form of a check sent in the mail. All data collected are confidential and will be reported in the aggregate only.
I would like to reassure you that this research is conducted in compliance with Council of American Survey Research Organizations (CASRO) and European Society for Opinion and Marketing Research (ESOMAR) guidelines.
We will comply with all relevant laws protecting your personal data.
You have the right to withdraw at any time
Your responses will be used by us and the sponsoring company for market research purposes only;
Your responses will be treated in confidence and will not be used for any other purposes or disclosed to any third party without your approval;
Your responses will be collated with other respondents and presented to the sponsor in aggregated and anonymized form;
The interview will be recorded to help us with our analysis, and the recording may be shared with members of the insight/marketing team from the sponsoring company for market research purposes only.
Are you willing to proceed?

Yes

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* 3. How do you describe your gender?

Cisgender Man (Assigned male at birth and currently identify as a man)

Cisgender Woman (Assigned female at birth and currently identify as a woman)

Trans Man, FTM (Female to Male)

Trans Woman, MTF (Male to Female)

Non-Binary

If you wish to self-describe in another way, please share:

Prefer not to answer

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* 4. How do you describe your sexual orientation?

Asexual

Bisexual

Gay

Heterosexual or straight

Lesbian

Pansexual

Queer

If you wish to self-identify in another way, please share:

Prefer not to answer

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* 5. What is your birthdate? And, what is your current age?

Birthdate:

Current age:

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* 6. Have you been diagnosed with any of the following conditions? Please select all that apply.

AIDS

Hepatitis B

Hepatitis C

Hepatitis D

High blood pressure

Human immunodeficiency viruses (HIV)

Non-alcoholic steatohepatitis (NASH)

Osteoarthritis

Type 2 Diabetes

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* 7. In order to represent all groups equally, are you of Hispanic, Latino, or of Spanish origin?

Yes

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* 8. What language(s) do you usually speak at home?

Only Spanish

Spanish more than English

Both equally

English more than Spanish

Only English

Other language