HIVST Results

HIVST Results
County*
How did you receive the HIV Self-Test Kit?

In person from a peer outreach workerIn the mailIn person at a community event
Age*

Under 1818-2425-3435-4445-5455-6465-7475 and olderPrefer not to Answer
Gender*

Cis-FemaleCis-MaleTrans-MaleTrans-FemaleNonbinaryQueerIntersexTwo-SpiritPrefer Not to AnswerQuestioningOther
Sexual Orientation*

HeterosexualGayLesbianBisexualPolyamorousQueerAsexualPansexualPrefer not to answerQuestioningOther
Race*

BlackLatinxNative American/IndigenousAsianHispanicAsian SubcontinentWhite/CaucasianPrefer not to answerOther
What was the result of your OraQuick HIV Self-Test?*

Reactive (2 lines)Negative (1 line)Unsure
Have you gone for confirmatory testing?

YesNo
What was the result of your confirmatory testing?

HIV positiveHIV negativeOther
Do you want us to connect you to services (confirmatory testing, PReP/PEP, etc.)?

YesNo
What is your follow up information (phone number or email)?
If you are a peer outreach worker with FLHRC, what are your initials?
For peer outreach workers: Date of Services, if known.

MonthDayYear
Date
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