Peer Survey

Peer Leadership Interest Form

We're excited you are interested in the E-P-I-C+ Peer Leadership Program! Please tell us a little about yourself and a member of our team will reach out to you with more information. (There are no right or wrong answers here!) If you have a specific question about the program, please reach out to us at info@engagingarkansas.org.
Contact Info

Please provide your contact information and the best way to reach you.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Way to Be Contacted:*
Stigma

Please answer these questions about your personal experiences with HIV stigma.

I have encountered HIV stigma with my:*

Choose how much you agree with the following statements:*

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
My uderstanding of BASIC HIV INFORMATION is very strong.
I feel I could explain basic HIV information to another person.
My understanding of HIV TRANSMISSION is very strong.
I feel I could explain HIV transmission to another person.

Why would you like to join this training?*
Demographics
Age*

18-2627-3435-4445-5455 and older
Gender Identity*

Cisgender manCisgender womanTransgender man (FTM)Transgender woman (MTF)Non-binaryNot listed
Sexual Identity*

Straight/HeterosexualGayLesbianBisexualQueerQuestioningTerms do not apply
Do you identify as Hispanic/Latino/a, or of Spanish Origin?*

Hispanic/Latino/a, or of Spanish OriginNon-Hispanic/Latino/a, or of Spanish Origin
Race (mark all that apply)

Black or African-AmericanAmerican Indian or Alaska NativeWhite or European AmericanAsianNative Hawaiian/Pacific IslanderOther Race
Should be Empty:

Peer Leadership Interest Form