At-Home HIV Test: Pre-Screening (Final)

Demographic Form (HIV Self Test)

1. Thank you for submitting a request for an at-home HIV test kit. In order to send the test kit to you, please provide your mailing information below: *This question is required.

First Name

Last Name

Street Address (w/ apt)

City

State

Zip

Email Address

Phone Number

2. Preferred Method of Contact: *This question is required.

3. Would you like to pick up your test directly from the Pride Center via Curbside ( 255 S Champlain St, Ste. 12, Burlington, VT)?

Our HIV testing program is fully grant funded by the Vermont Department of Health, therefore we have a questionnaire on the next page collecting demographic and sexual health information. The next page of questions are standard for our in-person HIV testing program and will not be connected to the information on this first page. All data sent to the Vermont Department of Health will be de-identified and confidential.