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PROGRAM ENROLLMENT FORM
Date:
/
Month
/
Day
Year
Date
First 2 Letters of First Name
*
First 2 Letters of Last Name
*
1. What is your birth date?
*
/
Month
/
Day
Year
Date
2. What state do you reside on?
*
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
3. How long have you lived in this state?
*
6 months or less
6 months to a year
1 to 3 years
3 to 5 years
5 years or more
4. Were you born a male or female?
*
Male
Female
Don't Know
Did not ask
Refused to Answer
5. How do you view your gender now (i.e., what is your current gender)?
*
Male
Female
Transgender – Male to Female
Transgender – Female to Male
Don’t know
Did not ask
Refused to answer
6. What best describes your ethnicity?
*
Hispanic or Latino
Not Hispanic or Latino
Don’t know
Did not ask
Refused to answer
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7. What best describes your race? (check all that apply)
*
American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or Pacific Islander
White
Don’t know
Did not ask
Refused to answer
8. What is your marital status?
*
Single, never married
Married
Married, but separated
Divorced
Don’t know
Did not ask
Refused to answer
9. Are you currently pregnant? (only if female)
Yes
No
Don't Know
Did not ask
Refused to answer
10. Are you currently pregnant? (only if female)
Yes
No
Don't Know
Did not ask
Refused to answer
11. Have you ever had an HIV test?
*
Yes
no
Don't Know
Did Not Ask
Refused to Answer
12. Date
/
Month
/
Mark Day as 01
Year
Date Picker Icon
13.What is your HIV test result?
*
HIV-Positive (HIV+)
HIV-Negative (HIV-)
Don’t know
Did not ask
Refused to answer
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Next
14. Are you receiving medical care or treatment for HIV?
Yes
No
Don't Know
Did not ask
Refused to answer
15. In the past 12 months, were you diagnosed with an STD (not including HIV)?
*
Yes
No
Don't Know
Did not ask
Refused to answer
15A. If yes what STD were you diagnosed with?
Syphilis
Chlamydia
Gonorrhea
Don’t know
Did not ask
Refused to answer
If Other please specify
16. Have you ever used a condom?
Yes
No
17. Have you had sexual intercourse (vaginal or anal sex) in the past 12 months?
Yes
No
Did not ask
Refused to answer
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Next
18. Please indicate if you have engaged in the any of the following behaviors in the last 12 months:
Yes
No
Don't Know
a. Sex with a female
b. Sex with a male
c. Sex with a transgender
d. Oral sex with a female
e. Oral sex with a male
f. Exchanged sex for drugs, money or something you needed
g. Sex while intoxicated and/or high on drugs
h. Sex with an injection drug user (IDU)
i. Sex with someone who is HIV positive
j. Sex with a person of who HIV status you did not know
k. Sex with a person who exchanges sex for drugs/money
l. Sex with a man who has sex with other men (MSM)
m. Sex with an anonymous partner
n. Sex with a hemophiliac or transplant recipient
o. Sex without using a condom
p. Injected Drugs
q. Shared injections drug equipment
The next set of questions focus on your sexual activity within the
last 3 months
.
19. In the past 3 months, have you had only one main partner?
Yes
No
20. How long has he or she been your only main partner?
Less than three months
Three to six months
Six months to a year
One year or more
21. How often do you use condoms with your main partner for:
Vaginal Sex
Anal Sex
Oral Sex
Every time
Sometimes
Never
Don't Know
Refused to Answer
22. During your most recent sexual encounter with your main partner, did you use condoms during vaginal sex?
Yes
No
23. Who persuaded whom to use the condom during this encounter?
You persuaded your partner
Your partner persuaded you
It was a mutual decision
24. During your most recent sexual encounter with your main partner, did you use condoms during anal sex?
Yes
No
25. Who persuaded whom to use the condom during this encounter?
You persuaded your partner
Your partner persuaded you
It was a mutual decision
26. During your most recent sexual encounter with your main partner, did you use condoms during oral sex?
Yes
No
Back
Next
27. Who persuaded whom to use the condom during this encounter?
You persuaded your partner
Your partner persuaded you
It was a mutual decision
28. Did the condom break/slip during your most recent sexual encounter with your main partner?
Yes
No
Don't Know
Not Asked
Refused to Answer
29. At what point was the condom put on during your most recent encounter?
Before the sexual encounter began Right before a male partner ejaculated Right before vaginal, anal, or oral penetration Don’t know
Refuse to answer
30. If you have had more than one partner, how many partners have you had in the past 3 months?
31. In the past 3 months how often did you use condoms with these partners for:
Every time
Sometimes
Never
Don't Know
Refused to Answer
Vaginal Sex?
31. In the past 3 months how often did you use condoms with these partners for:
Every time
Sometimes
Never
Don't Know
Refused to Answer
Anal Sex?
31. In the past 3 months how often did you use condoms with these partners for:
Every time
Sometimes
Never
Don't Know
Refused to Answer
Oral Sex?
32. Who persuaded whom to use the condom during these encounters?
You persuaded your partners
Your partners persuaded you
Either you or your partners
It was a mutual decision
33. Did the condom break/slip during any of these encounters?
Yes
No
Don't Know
Not asked
Refused to Answer
34. At what point was the condom put on during these encounters?
Before the sexual encounter began Right before a male partner ejaculated Right before vaginal, anal, or oral penetration
Don’t know
Refuse to answer
Back
Next
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Submit
Should be Empty: