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At Home HIV Test Kit Request
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* Indicates required question
Name (First and Last)
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Your answer
Mailing Address (Street, Apartment)
*
Your answer
Mailing Address (City, State, Zip)
*
Your answer
Gender
*
Male
Female
Other
Prefer not to say
What best describes your sexual orientation?
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Heterosexual or Straight
Gay
Lesbian
Bisexual
Other
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What is your birth year?
*
Your answer
Email
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Your answer
Do you identify as Hispanic?
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Yes
No
What is your race
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Black/African American
American Indian/Alaska Native
Asian/Pacific Islander
White
Two or more races
Other
Unknown
What might have made you vulnerable to acquiring HIV? (select all that apply)
*
Vaginal or anal sex without a condom
Injection drug use
Sharing drug-use equipment
Something else
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How would you like to receive your At-Home HIV Test Kit?
*
Mail At-Home Test Kit
Pick up At-Home Test Kit at Samaritan Ministry (Knoxville, TN)
How did you hear about Samaritan Ministry's At-Home Test Kit service?
Your answer
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