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. Age Only an integer value may be entered in this field. Location Name of location, business, event, street or cross street where outreach is conducted Gender Choose one of the following answers Man Woman Transgender Other: No answer Race/ethnicity Choose one of the following answers Black/African American White Latinx Asian/Pacific Islander Native American Other: No answer Zip code of participant Your answer must be between 00000 and 99999 Only an integer value may be entered in this field. Primary language? Choose one of the following answers English Spanish Other: No answer Has this the person recieved services from HEPPAC before? Yes No 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. 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 What types of population does the participant feel they represent? Check all that apply Sex for money Sex for drugs Sex for survival Runaway Immigrant Youth at risk Main partner Customer Piercing/tattooing Transgender Gay/MSM/lesbian Homeless Multiple sex partners IDU Crack user Speed user Alcohol user Other substance user Woman at risk Partner of IDU Partner of HIV+ person HIV+ Non-injection heroin Inhalants user Partner of ex-offender Bisexual Meth user Ecstasy user Heterosexual Marijuana Recently released Ex-offender Foster/group home youth Student/alternative school Ex-juvenile hall Street hustler Pimp Former substance user Syrup Oxycontin/narco Former-foster/grouphome Molly 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 Linkages to other services? Check all that apply Employment Housing Food Social services Healthcare coverage Mental health program Needle exchange Substance use program ID card Other: Submit Load unfinished survey Resume later Please confirm you want to clear your response? Exit and clear survey ×
