Thank you for taking the time to complete this survey on community perception of services available to HIV negative individuals. The survey was created by the South Florida AIDS Network and the HIV Prevention Program of the Florida Department of Health in Broward County. Your feedback is important to us in how we can better improve access to services for all communities. This survey should take no more than 10 minutes. This survey is confidential and your answers will be completely anonymous. We ask that you answer every question as honestly as possible. If you can’t answer or don’t want to answer a question, it’s okay, just move on to the next one.  

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1. Date:

Date

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2. Are you currently living in Broward County?

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3. Residency Zip code

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4. What is your age?

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5. What is your current gender identity?

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6. What gender were you assigned at birth?

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7. What is your Country of origin/nationality?

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8. What is your race/ethnicity?

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9. What is your sexual orientation?

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10. Is your current housing situation stable?

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11. If No, please explain?

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12. What is your current yearly household income?

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13. In your opinion, are the following services and resources available to HIV negative people? Please check the box that comes closest to your opinion.

  Yes, this service is available No, this service is not available I don’t know if this service is available Decline to answer
Outpatient Medical Care: Visits to doctor’s office or clinic for medical care
Case Management: Case managers help clients receive services and then follow-up on their care
PrEP Medications: Pills to prevent HIV transmission
Dental/Oral Health: General teeth and mouth care, dentures, oral surgery, etc.
Health Insurance: Helps pay insurance costs or co-pays if client has private insurance
Behavioral Health Services: Professional counseling, therapy, or support groups
Substance Use Treatment: Professional counseling for drug or alcohol addiction
Nutritional Counseling: Professional counseling for healthy eating habits
HIV Counseling and Testing: HIV testing in healthcare or non-healthcare settings
Home Health Care: Professional healthcare services in a client’s home by a licensed/certified home-health agency
Hospice Services: Nursing and counseling services for the terminally ill and their family
Food Bank or Food Vouchers: Food bags, grocery certificates, home-delivered meals, and nutritional supplements
Transportation: Help getting to the doctor’s office
Outreach: face-to-to face, in neighborhoods or venues, information and recruitment for prevention services
Health Education/Risk Reduction: Education provided on HIV prevention, HIV awareness and other related topics
PrEP Adherence: Instructions on how to take PrEP medications properly
Legal Support: Help clients with legal issues (will, living will, etc.)
Rehabilitation: Physical therapy, occupational therapy, speech therapy, low vision training, etc.
Peer Mentoring: Support and counseling from community members
Housing: Helping find and/or maintain a place to live
Needle Exchange Program: access to a free needle exchange program for clean needles

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14. Please check the boxes next to the services that you have used or needed in
the past 12 months.

  I received this service without difficulty I received this service but it was difficult to get I needed this service but was unable to get it I did not need this service I don’t know if this service is available
Outpatient Medical Care: Visits to doctor’s office or clinic for medical care
Case Management: Case managers help clients receive services and then follow-up on their care
PrEP Medications: Pills to prevent HIV transmission
Dental/Oral Health: General teeth and mouth care, dentures, oral surgery, etc.
Health Insurance: Helps pay insurance costs or co-pays if client has private insurance
Behavioral Health Services: Professional counseling, therapy, or support groups
Substance Use Treatment: Professional counseling for drug or alcohol addiction
Nutritional Counseling: Professional counseling for healthy eating habits
HIV Counseling and Testing: HIV testing in healthcare or non-healthcare settings
Home Health Care: Professional healthcare services in a client’s home by a licensed/certified home-health agency
Hospice Services: Nursing and counseling services for the terminally ill and their family
Food Bank or Food Vouchers: Food bags, grocery certificates, home-delivered meals, and nutritional supplements
Transportation: Help getting to the doctor’s office
Outreach: face-to-to face, in neighborhoods or venues, information and recruitment for prevention services
Health Education/Risk Reduction: Education provided on HIV prevention, HIV awareness and other related topics
PrEP Adherence: Instructions on how to take PrEP medications properly
Legal Support: Help clients with legal issues (will, living will, etc.)
Rehabilitation: Physical therapy, occupational therapy, speech therapy, low vision training, etc.
Peer Mentoring: Support and counseling from community members
Housing: Helping find and/or maintain a place to live
Needle Exchange Program: access to a free needle exchange program for clean needles

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15. What are your current three most significant needs?

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16. Have you tested for HIV?

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17. If so, what was the date of your last HIV test?

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18. If so, what was the result of your last HIV test?

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19. Are you aware of medications and/or treatment that can be used to keep you from getting HIV?

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20. Have you ever used any medications and/or treatment to keep you from getting HIV?

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21. If so, where did you get it?

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22. In the past 6 months, when I had sex I used condoms (CHECK ONE):

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23. Is there anything else you would like to tell us about your health care needs that was not covered in this survey?

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