Community Survey
Anthony Munger BSW LSW CPT BBS

With anti-LGBTQ+ legislation, cuts to DEI programs, healthcare discrimination, and rising mental health concerns, these questions can help:

- Identify barriers to care and support services
- Gather data on discrimination and violence to advocate for policy change
- Ensure LGBTQ+ individuals feel seen and heard
- Improve access to affirming healthcare, harm reduction, and mental health resources
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Email *
Zipcode / Postal Code *
Birthdate
MM
/
DD
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YYYY
Gender *
Orientation *
Race / Ethnicity *
Number of People in Household
Clear selection
Approximate Household Income
Do you consider yourself to have a disability
Clear selection
Do you have health insurance?
Clear selection
How would you rate your overall mental health?
Poor
Excellent
Clear selection
Have you been tested for HIV before?
Clear selection
If yes when was you last HIV test?
MM
/
DD
/
YYYY
What is your current HIV status?
Clear selection
Are you currently taking an antiretroviral therapy?
Clear selection
Have you heard of PrEP (Pre-Exposure Prophylaxis) for HIV prevention?
Clear selection
Do you know where to get PrEP if you wanted to?

Clear selection
Have you heard of PEP (Post-Exposure Prophylaxis) for HIV prevention?
Clear selection
Have you shared needles or any other drug-related items with anyone in the last 12 months?
Clear selection
Do you carry or have access to Naloxone (Narcan) to reverse opioid overdoses?
Clear selection
In the past six months, how many sexual partners have you had?
Do you use protection (condoms) consistently duing sexual encounters?
Clear selection
Do you have supportive family or friends?
Clear selection
Have you received both doses of the mpox vaccine?
Clear selection
Have you ever delayed or avoided seeking medical care due to concerns about discrimination or lack of LGBTQ-affirming providers?
Clear selection
Have you ever experienced rejection from family or community due to your gender identity or sexual orientation?
Clear selection
Do you feel connected to the LGBTQ+ community in your area?
Clear selection
For trans or non-binary respondents: Have you legally changed your name and/or gender marker on identification documents?
Clear selection
Have you ever felt unsafe in a public space because of your gender identity or sexual orientation?
Clear selection
Have you ever faced housing instability or homelessness due to being LGBTQ+?
Clear selection
Do you feel comfortable discussing substance use with a healthcare provider?
Clear selection
Do you feel informed about how to contact elected officials regarding LGBTQ+ issues?
Clear selection
Thank you for participating in our survey. Your responses contribute to a deeper understanding of the experiences, needs, and challenges faced by the LGBTQIA+ community. This information helps strengthen my advocacy efforts and ensures that our voices are heard where it matters most. All responses will be used in aggregate form, and no personally identifying information will be disclosed to anyone else ever. Your input is invaluable in building a more informed and supportive community—thank you for being part of this important work.
 *
It is okay for the researcher to contact you regarding further information on your responses.
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Submit
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