Ending the HIV Epidemic Survey 2023

On behalf of Valley AIDS Council and its collaborative partner TAP-in, we would like to thank you for taking the time to fill out our screening form. The intention of this screener is to gather input from consumers and persons working with diverse Latinx populations from HRSA-funded Ending the HIV Epidemic jurisdictions.

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* 1. Please enter your contact information.

Name

Company

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

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* 2. What is your role at your organization?

Clinician

Mental Health Provider

Case Manager

Educator

Community Health Worker

Administrator

Advocate

Consumer

Other (please specify)

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* 3. Are you of Hispanic or Latinx origin?

Yes

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* 4. What is your racial background? Please select all that apply.

White or Caucasian

Black or African American

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

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* 5. What is your gender?

Female

Male

Transwoman

Transman

Gender Fluid

Other Gender Identity (please specify)

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* 6. What percentage of the population you serve are Latinx?

0% to 25%

25% to 50%

50% to 75%

75% to 100%

Please indicate which of the states/counties you serve (if applicable).

Ending the HIV Epidemic Survey 2023

Question Title

* 1. Please enter your contact information.

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* 2. What is your role at your organization?

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* 3. Are you of Hispanic or Latinx origin?

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* 4. What is your racial background? Please select all that apply.

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* 5. What is your gender?

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* 6. What percentage of the population you serve are Latinx?

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* 7. West Coast

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* 8. Midwest

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* 9. South

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* 10. East Coast/Caribbean