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TRANSGENDER SURVEY
Contact Information
* 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:
*
MM
/
DD
/
YYYY
1.
Do you identify as transgender? (Please specify)
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Your answer
2.
Do you know your Human Rights as a transgender? (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 transgender?
*
Yes
No
Maybe
Other:
4.
Are you comfortable asking for condoms and especially lubricant at clinic or hospital?
*
Yes
No
Maybe
Other:
5.
Are you comfortable in seeking treatment at clinic or hospital as a result of penetrative sex?
*
Yes
No
Maybe
Other:
6.
Have you experienced any bad service at clinic/hospital because you are transgender? 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?
*
Yes
No
Maybe
Other:
9.
Are you comfortable going to police station to report being physically assaulted by any member of the public because you are transgender? If NO, please also fill out POLICE STATION SURVEY
https://forms.gle/xcrCn2RTKQ6pdw9M7
*
Yes
No
Maybe
Other:
10.
Are you comfortable going to police station to report being physically assaulted by a sexual partner? If NO, please also fill out POLICE STATION SURVEY
https://forms.gle/xcrCn2RTKQ6pdw9M7
*
Yes
No
Maybe
Other:
11.
Are you comfortable reporting to the lawyer for legal representation for being harassed or bullied because you are transgender?
*
Yes
No
Maybe
Other:
12.
Are you comfortable talking to a social worker about any problems you may have in your life because you are transgender?
*
Yes
No
Maybe
Other:
13.
Have you experienced any bad service at police station because you are transgender? If YES, please also fill out POLICE STATION SURVEY
https://forms.gle/xcrCn2RTKQ6pdw9M7
*
Yes
No
Maybe
Other:
14.
Do you need any help from Tholwana e Molemo? Yes/No (Please Describe)
*
Your answer
15.
Would you recommend Tholwana e Molemo Services to other transgenders?
*
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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