Toggle navigation Load unfinished survey Resume later default Caution: JavaScript execution is disabled in your browser or for this website. You may not be able to answer all questions in this survey. Please, verify your browser parameters. Gender Choose one of the following answers Man Woman Transgender Other: No answer Age Only an integer value may be entered in this field. Primary language? Choose one of the following answers English Spanish Other: No answer Race/ethnicity Choose one of the following answers Black/African American White Latinx Asian/Pacific Islander Native American Other: No answer Number of syringes collected from participant Only an integer value may be entered in this field. Number of syringes distributed to participant Only an integer value may be entered in this field. How many people is the participant picking up syringes for Only an integer value may be entered in this field. Is this the person's first visit to the exchange? Yes No No answer How did you hear about us? Choose one of the following answers Mobile service Word of mouth Other: No answer Would you like to be screened for HIV/HCV? Yes No No answer Zip code of participant Your answer must be between 00000 and 99999 Only an integer value may be entered in this field. Would you like to receive medical treatment? Yes No No answer Vaccinated? Yes No No answer Are you interested in getting vaccinated? Yes No No answer Linked to vaccination? Yes No No answer Type of vaccine? Choose one of the following answers Moderna Johnson & Johnson Pfizer Other No answer Other: Booster? Yes No No answer Would you like to receive food? Yes No No answer Would you like MAT services? Yes No No answer Submit Load unfinished survey Resume later Please confirm you want to clear your response? Exit and clear survey ×
