Home-Based HIV Test Questionnaire

1. How do you describe your gender identity? *

2. What category best describes your sexual orientation? *

3. What racial or ethnic group(s) do you consider yourself a member of? Click all that apply. *

4. How old are you? *

5. Have you been told by a healthcare professional that you have HIV or AIDS? *

Yes
No

6. Are you currently taking medication for prevention (PrEP) or treatment of HIV? *

Yes
No

7. Have you ever had condomless sex? *

Yes
No

8. Have you shared needles, syringes, or other drug injection equipment to inject drugs, hormones, vitamins, or steroids? *

Yes
No

9. Have you ever been tested for HIV? *

Yes
No

10. If you have been previously tested, when was your last test? *

11. Would you like a testing counselor to provide support during the home testing process? *

Yes
No

If you prefer support, then a testing counselor will contact you via email in 1 to 2 business days to schedule a telehealth appointment. Telehealth appointments may be done via phone or video conferencing.

12. Would you like free condoms with your HIV self-testing kit? Please check the box if you have a latex allergy. *

Yes
No
I have a latex allergy

13. Full Name *

First

Last

By providing your full name, you give consent to have a free HIV self-testing kit with educational materials mailed to you and that the HIV self-test is for your exclusive use. You agree to hold harmless AIDS Resource, including its staff, directors, and agents, from any and all liability that may arise from self-testing.

14. Street Address *

15. Apt/Suite/Other

16. City *

17. Zip Code *

18. What county do you live in? *

19. Email *

Email

Confirm Email

You will receive a follow-up questionnaire from info@atestisbest.com within 3 days of receipt of the self-testing kit.

20. Would you like to have the HIV self-testing kit mailed to you or would you like to pick up the kit at one of our offices? *

Mailed
Curbside pick up

If you selected 'Curbside pick up,' you will receive an email from info@atestisbest.com within 1 business day to schedule a date and time to pick up your kit.

Williamsport Office

State College Office