Community Empowerment Outreach Survey

1. Age *This question is required.

• 17 or younger
• 18 to 24
• 25 to 34
• 35 to 44
• 45 to 54
• 55 to 64
• 65 to 74
• 75 or older

2. Ethnicity *This question is required.

• Hisapnic
• Non-Hispanic

3. Race (choose all that apply): *This question is required.

• American Indian/Alaskan Native
• Asian
• Black/African American
• Native Hawaiian/Pacific Islander
• White

5. Which of the following most accurately describes you? (Choose all that apply) *This question is required.

• Male
• Female
• Non-binary
• Transgender
• Intersex
• Let me answer: Please enter an 'other' value for this selection.
• I prefer not to disclose

6. Do you know your HIV status? *This question is required.

• Yes
• No

7. Are you or anyone you know living with HIV? *This question is required.

• Yes
• No
• I prefer not to disclose

8. Do you receive Ryan White Services? *This question is required.

• Yes
• No
• I prefer not to disclsoe
• I am not sure what Ryan White services are...

9. Have you heard about the Ryan White HIV Planning Council (HIVPC)? *This question is required.

• Yes
• No

11. How do you pay for your health care services? (Select all that apply) *This question is required.

• Insurance
• Insurance through the ACA (Obamacare)
• Medicare
• Medicaid
• Ryan White
• I do not receive healthcare services
• Other: Please enter an 'other' value for this selection.

12. What are some topics affecting the HIV community that you would like to know more about? *This question is required.

• Transportation
• Housing
• HIV Prevention
• Available HIV Services
• HIV Medications
• Social and Community Support
• Other Please enter an 'other' value for this selection.

13. Would you be willing to participate in a(n): *This question is required.

Space Cell	Yes	No
Education forum about one of the topics listed above?	Education forum about one of the topics listed above?: Yes	Education forum about one of the topics listed above?: No
Focus Group?	Focus Group?: Yes	Focus Group?: No