Application for Research Regarding PrEP (11/21)

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Email *

What is your first name? *

What is your last name?

What is your cellular telephone number? *

Which time zone do you live in? *

What is your ethnicity? *

To which gender do you most identify? *

Female

Male

Transgender Female

Transgender Male

Gender Variant/Non-Binary

Prefer not to say

Other:

Are you, or any member of your household/immediate family employed by any of the following industries/organizations? *

Advertising

Public Relations

Marketing/Market Research

Pharmaceuticals/Biotechnology

Health Insurance

Food and Drug Administration (FDA)

Other government/state healthcare regulatory body

NONE OF THESE

Required

Please select any of the roles/positions that describe you. Please select all that apply. *

Doctor, nurse or other healthcare provider

Paid or unpaid HIV counselor or treatment advisor

NONE OF THESE

Required

How old are you? *

In what state do you currently live? *

Which county do you live in? *

Which of the following best describes the area in which you live? *

Urban

Suburban

Rural

Have you ever been diagnosed with HIV/AIDS? *

Yes

How many sexual partners have you had in the past year? *

NONE

1-4

5-9

10 or more

Thinking of your sexual lifestyle, please select all statements that would apply to you. I sometimes or regularly have: *

Sex with an HIV positive partner

Anal sex without a condom

Sex without a condom with others who may be using injectable drugs

Sex while under the influence of a mind-altering substance (drugs/alcohol)

Sex with other people while maintaining a consistent sexual relationship (a non-monogamous relationship)

Sex for the exchange of food, housing, or other needs

Sex with someone whose HIV status I did not know

None of the above

Prefer not to answer

Required

How would you categorize your awareness regarding drugs to prevent HIV also known as PrEP *

Not aware at all

Have limited awareness

Have moderate awareness

Very aware

How would you categorize your level of awareness regarding drugs to TREAT HIV (Atripla, Prezista, Truvada, ect) *

Not aware at all

Have limited awareness

Have moderate awareness

Very aware

Please select on of the following statements, if any, that describes your experience with PrEP for HIV prevention. *

I currently use PrEP regularly for HIV prevention

I currently use PrEP for HIV prevention, but only take it when I think I may need it

I have previously used PrEP for HIV prevention, but have completely stopped using it

I have NEVER used PrEP for HIV prevention

Prefer not to answer

Required

Would you be willing to consider using PrEP to prevent HIV in the future? *

Yes, I would be willing to consider using PrEP in the future

I don't feel I know enough about PrEP to consider it now, I would like to/need to learn more

No, I would not be willing to consider using PrEP in the future

Do you have a desktop/laptop with internet access? *

Yes

What is your primary internet browser? *

Internet Explorer

Firefox

Chrome

Safari

Other:

These interviews are typically audio recorded strictly for our researchers to review the responses. Would you be comfortable with audio recording? *

Yes

What is your email address? *

Completion of this application does not constitute a confirmation for participation. Not all applicants will qualify nor will everyone receive an email with the survey link. If you are selected to participate, you will be contacted by our team via telephone to get scheduled for the interview. *

I understand

I do not understand, please remove me from your database

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