HIV Self-Testing Kits
As an agency serving Wayne, Oakland, Macomb, and Monroe County. We are currently offering HIV Self-Testing Kits for those who are homebound, have limited transportation, or live more than 30 miles from a testing location. 


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Consent to the Human Immunodeficiency Virus Antigen and/or Antibody Test
Human Immunodeficiency Virus Antigen and/or Antibody Test
I have been informed that my blood obtained from a finger stick or vein, a plasma sample, a urine sample, or an oral sample from my mouth, will be tested for antigens and/or antibodies to the Human Immunodeficiency Virus, the virus that causes AIDS. I acknowledge that I have been given an explanation of the test, including its uses, benefits, limitations, and the meaning of test results. I have been informed that the HIV test results are confidential and shall not be released without my written permission. I understand that I have the right to withdraw my consent for the test at any time before the test is complete.

By providing a working phone number at which I can be reached, I hereby consent to be tested for HIV and permit the Michigan Department of Health and Human Services to contact me regarding the result of my test and to offer prevention, care, and partner services.


By my typing in my name below, I consent to be tested for HIV:
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HIV Self-Testing Kits
First Name: *
Last Name *
Phone number: *
Date of birth: *
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Address Line 1:  *
Address Line 2:
City *
Zip code *
State:  *
Sex at birth: *
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Gender Identity *
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Race:  *
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Ethnicity: *
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Do you have reliable transportation? 
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Do you have health insurance? 
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If you answered yes, what type of insurance do you have?

If uninsured, I am:
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Have you ever been tested for HIV? * 
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How many times were you tested for HIV during the last 12 months? Please enter a number 
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Did you ever test positive for HIV? 
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If yes, what is the date? If no, please select 01/01/001 *
Approximate date is acceptable
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What is the gender of your sexual partner within the past year? Select all that apply: 

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What type of sex do you have with your partner(s)? Select all that apply:

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How often do you use barriers (Condoms) when having sex?  *
Have you tested positive for any STI's within the last 90 days? 
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Have you had sex with someone while you were intoxicated (Under the influence of Alcohol/Substances)?


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If you answered yes, would you like to be connected with someone who can privately assist you with accessing supplies for using drugs (sterile needles, tourniquets, ... etc)?

For urgent assistance contact the SSP outreach number at: (586)330-8040
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Have you exchanged money or drugs for sex in the past 12 months?
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Have you ever heard of PrEP? 
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Are you currently on PrEp?
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How did you hear about us? 

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By typing in my name below, I agree that I reviewed the HIPAA Notice of Privacy Practices    
Please acknowledge you will be contacted by one of ACCESS CHRC - HIV Intervention staff to discuss your HIV Self-Testing Kit and linkage to available resources if needed. 

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Required
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