Charlotte TGA Needs Assessment, 2018 Question Title * 1. Please provide the first and third letters of your first name and the first and third letters of your last name. As an example, it your name was John Doe, you would enter JH and then DE. Secondly, enter your date of birth in the two digit MONTH/DAY/YEAR format. As an example, if you were born on December 25, 1990, you would enter 12/25/90. First and Third of First Name First and Third of Last Name Date of Birth MM/DD/YY OK Question Title * 2. What is your Zip Code? If not known, what county do you live in? OK Question Title * 3. What year were you diagnosed with HIV? If unknown, please note in comment box. Year Diagnosed: Unknown OK Question Title * 4. In what city and state were you FIRST diagnosed with HIV? OK Question Title * 5. What year were you diagnosed with AIDS? If you have been diagnosed with AIDS, what city and state were you FIRST diagnosed with AIDS? Year Diagnosed: Unknown Do not have AIDS; only HIV positive City and State diagnosed with AIDS: OK Question Title * 6. Where did you first learn about your positive diagnosis? Emergency Room Doctor's VIsit Hospital Health Fair/Testing Site Blood Bank OK Question Title * 7. Do you know how you may have acquired HIV/AIDS? (Please check all that may apply) Male sex with male Injection Drug Use Health Care Worker Female sex with female Sex with Drug User Mother with HIV/AIDS Heterosexual Sex Sexual Assault Prison Transfusion Other (please specify) OK Question Title * 8. Do you currently have health insurance? No, I do not have any health insurance Yes, I have Private Health Insurance Yes, I have Medicare Yes, I have Medicaid Yes, I have VA (Veteran's Administration) Yes, I have Blue Cross/Blue Shield Yes, I have ADAP Yes, Other (please specify) OK Question Title * 9. When was the last time you saw a doctor to treat your HIV? Month: Year: OK Question Title * 10. What clinic/doctor's office do you go to for your HIV treatment? OK Question Title * 11. When was the last time you had a CD4 (T-Cell) Count? Month: Year: OK Question Title * 12. When was the last time you had a Viral Load test? Month: Year: OK Question Title * 13. Are you currently taking ART (HIV) medications? Yes No OK Question Title * 14. Are you currently being treated for a mental illness? Yes No OK Question Title * 15. Are you currently being treated for substance abuse? Yes No OK Question Title * 16. Have you ever been diagnosed with or treated for sexually transmitted infections (STIs, including syphilis, gonorrhea or chlamydia)? Yes No Don't Know Refuse to answer OK Question Title * 17. Are you now or have you ever been homeless? Never Currently homeless Been homeless in past two years, but not now Been homeless longer than past two years, but now now OK Question Title * 18. Do you currently Own your home Rent Live with a friend or relative Stay in a shelter Other (please specify) OK Question Title * 19. How much is your monthly rent or mortgage? Less then $300 $301-$400 $401-$500 $501-$600 $601-$700 More than $700 OK Question Title * 20. Are you currently employed? Yes No OK Question Title * 21. What is your approximate yearly income? $0 - $9,999 $10,000 - $19,999 $20,000 - $29,999 $30,000 - $39,999 $40,000 - $49,999 Over $50,000 OK Question Title * 22. What is your highest level of education? Grade school Some high school High School degree or GED Some college College degree Some graduate school Graduate school degree OK Question Title * 23. What is your sexual orientation? Gay Bisexual Straight Prefer not to answer Other (please specify) OK Question Title * 24. Have you been in jail or prison in the past six (6) months? Yes No OK Question Title * 25. Are you? Male Female Transgender Other (please specify) OK Question Title * 26. Do you consider yourself? African American American Indian Asian/Pacific Islander Caucasian Hispanic/Latino Multi-Racial Other (please specify) OK Question Title * 27. Were you born in the United States? Yes No. I was born in (write country) If no, how long have you lived in the U.S.? OK Question Title * 28. Is a language other than English most commonly spoken in your home? Yes No If so, what is that language? OK Question Title * 29. Need: As a person living with HIV/AIDS, what are the five (5) most important needs for you to get or stay healthy? Rank the top five (greatest need = no. 1, etc.) 1 2 3 4 5 6 7 8 9 10 11 12 13 Ambulatory Outpatient Health Services (going to your HIV doctor) 1 2 3 4 5 6 7 8 9 10 11 12 13 Medical Case Management 1 2 3 4 5 6 7 8 9 10 11 12 13 Dental Care 1 2 3 4 5 6 7 8 9 10 11 12 13 Medical Transportation 1 2 3 4 5 6 7 8 9 10 11 12 13 Substance Abuse Care 1 2 3 4 5 6 7 8 9 10 11 12 13 Mental Health Care 1 2 3 4 5 6 7 8 9 10 11 12 13 Psychosocial Support (Peers with HIV to help you arrange care) 1 2 3 4 5 6 7 8 9 10 11 12 13 Health Insurance 1 2 3 4 5 6 7 8 9 10 11 12 13 HIV Meds 1 2 3 4 5 6 7 8 9 10 11 12 13 Emergency Financial Services (money to help pay rent or utilities to keep you from being homeless) 1 2 3 4 5 6 7 8 9 10 11 12 13 Early Intervention Services (counselors or Peers to help you get linked to an HIV doctor soon after you are diagnosed) 1 2 3 4 5 6 7 8 9 10 11 12 13 Support Groups 1 2 3 4 5 6 7 8 9 10 11 12 13 Adequate Housing OK Question Title * 30. Need: As a person living with HIV/AIDS, what are the five (5) most important needs for you to get or stay healthy? Rank the top five (greatest need = no. 1, etc.) 1 2 3 4 5 6 7 8 9 10 11 12 13 Ambulatory Outpatient Health Services (going to your HIV doctor) 1 2 3 4 5 6 7 8 9 10 11 12 13 Medical Case Management 1 2 3 4 5 6 7 8 9 10 11 12 13 Dental Care 1 2 3 4 5 6 7 8 9 10 11 12 13 Medical Transportation 1 2 3 4 5 6 7 8 9 10 11 12 13 Substance Abuse Care 1 2 3 4 5 6 7 8 9 10 11 12 13 Mental Health Care 1 2 3 4 5 6 7 8 9 10 11 12 13 Psychosocial Support (Peers with HIV to help you arrange care) 1 2 3 4 5 6 7 8 9 10 11 12 13 Health Insurance 1 2 3 4 5 6 7 8 9 10 11 12 13 HIV Meds 1 2 3 4 5 6 7 8 9 10 11 12 13 Emergency Financial Services (money to help pay rent or utilities to keep you from being homeless) 1 2 3 4 5 6 7 8 9 10 11 12 13 Early Intervention Services (counselors or Peers to help you get linked to an HIV doctor soon after you are diagnosed) 1 2 3 4 5 6 7 8 9 10 11 12 13 Support Groups 1 2 3 4 5 6 7 8 9 10 11 12 13 Adequate Housing OK Question Title * 31. List any services that you need for HIV care that are difficult to access (hard to get). Ambulatory Outpatient Health Services (going to your HIV doctor) Medical Case Management Dental Care Medical Transportation Substance Abuse Care Mental Health Care Psychosocial Support (Peers with HIV to help you arrange care) Health Insurance HIV Meds Emergency Financial Services (money to help pay rent or utilities to keep you from being homeless) Early Intervention Services (counselors or Peers to help you get linked to an HIV doctor soon after you are diagnosed) Support Groups Adequate Housing OK Question Title * 32. Why are these services hard to get? OK Question Title * 33. List any services that you need for HIV care that you cannot get. OK Question Title * 34. Why can't you get these services? OK Question Title * 35. Thank you for your time in completing this survey. Your confidential responses will be valuable information for the Charlotte TGA Advisory Council. If you want to receive a $10 food voucher, please let us know where to mail it. Your contact information will remain confidential. Please allow 4 weeks for receipt of food voucher. Only ONE voucher per eligible Ryan White client. Name Address City/Town State ZIP/Postal Code OK DONE