Order your FREE In-home HIV test kit. While Supplies Last!!

Thank you for your interest in this new free HIV self-testing program! 

This request form takes just 3 minutes to complete.

The test you’ll receive in the mail is an OraQuick Oral Antibody test; it is performed by placing a swab on the lining of your mouth. Results take 20 minutes to process. Please complete the below details and click the submit button at the end of the form. If you have any questions, please contact Venesha Heron, Connecticut Department of Public Health, via email at Venesha.Heron@ct.gov.

Please note this pilot project is only available to Connecticut residents, while supplies last.

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* 1. Agency Providing In-Home Test Kit(s)?

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* 2. When were you last tested for HIV?

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* 3. Within the last 12 months have you had?

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* 4. Have you ever heard of Pre-Exposure Prophylaxis (PrEP)?  
Note. PrEP is when people at risk for HIV take daily medicine to prevent HIV.

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* 5. What best describe your sexual orientation?

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* 6. Which best describe your use of Pre-Exposure Prophylaxis (PrEP)?

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* 7. Please identify your gender

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* 8. Please identify your race/ethnicity

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* 9. Age

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* 10. Country of Birth

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* 11. Please enter your contact information (Note. CONNECTICUT RESIDENTS ONLY!)               
Also, leave us your phone number if you would like to be contacted.

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* 12. Name of Agency Submitting Information:

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