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MSM & GAY MEN SURVEY
* Indicates required question
Name and Surname
*
Your answer
Gender
*
Your answer
Age
*
Your answer
Sexual Orientation
*
Your answer
Email
*
Your answer
Address
*
Your answer
Phone number
*
Your answer
WhatsApp number
*
Your answer
Date:
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MM
/
DD
/
YYYY
1. Do you identify as MSM (Men who has Sex with Men) or Gay Man?
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Your answer
2. Do you know your Human Rights as a MSM/Gay Man? (Please describe)
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Your answer
3. Are you comfortable going to clinic/hospital for any treatment needed by you because you are MSM/Gay Man?
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Yes
No
Maybe
Other:
4. Are you comfortable asking for condoms and especially lubricant at clinic or hospital?
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Yes
No
Maybe
Other:
5.
Are you comfortable in seeking treatment at clinic or hospital as a result of anal sex?
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Yes
No
Maybe
Other:
6. Have you experienced any bad service at clinic/hospital because you are MSM/Gay? If yes, please also fill out CLINIC SCORE CARD.
https://forms.gle/JHm7JGvyYCk6rBwP9
*
Yes
No
Maybe
Other:
7. Do you know your status?/ Are you interested in being tested for HIV?
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Yes
No
Maybe
Other:
8. Are you comfortable going to police station to report being physically assaulted by any member of the public because you are MSM/Gay Man? If NO, please also fill out POLICE STATION SURVEY
https://forms.gle/xcrCn2RTKQ6pdw9M7
*
Yes
No
Maybe
Other:
9. Are you comfortable going to police station to report being physically assaulted by boyfriend/same sex partner/gay lover? If NO, please also fill out POLICE STATION SURVEY
https://forms.gle/xcrCn2RTKQ6pdw9M7
*
Yes
No
Maybe
Other:
10.
Are you comfortable reporting to the lawyer for legal representation for being harassed or bullied because you are MSM/Gay?
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Yes
No
Maybe
Other:
11.
Are you comfortable talking to a social worker about any problems you may have in your life because you are MSM/Gay Man?
*
Yes
No
Maybe
Other:
12.
Have you experienced any bad service at police station because you are MSM/Gay Man? If YES, please also fill out POLICE STATION SURVEY
https://forms.gle/xcrCn2RTKQ6pdw9M7
*
Yes
No
Maybe
Other:
13.
Do you understand how Tholwana e Molemo can help you as MSM/Gay Man?
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Yes
No
Maybe
Other:
14.
Do you need any help from Tholwana e Molemo? Yes/No (Please describe)
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Yes
No
Maybe
Other:
15.
Would you recommend Tholwana e Molemo Services to other MSM/Gay Men?
*
Yes
No
Maybe
Other:
16.
Can you give us one or two contacts that you know who may need our services?
Your answer
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