Harford County At Home HIV Testing Program

Demographics - Part 1

Question Title

1. What year were you born? (Required.)

Question Title

2. What is your exact birthday? (Required.)

Birthdate

Date

Question Title

3. What is your race?

American Indian/Alaskan Native

Asian/Pacific Islander

Black/African-American

White/Caucasian

None of the above

Other (please specify)

Question Title

4. What is your ethnicity?

Hispanic or Latino

Indian or South Asian

Arabic, Middle Eastern, or North African

None of the above

Other (please specify)

Question Title

5. What is your current health insurance status?

Insured through my employer

Insured through my spouse/relative

Insured through Medicare

Insured through Medicaid

Insured through a state or federal health insurance exchange

Uninsured

Question Title

6. What are the last 4 digits of your Social Security Number, if you have one?
This is a unique identifier for your test. It is completely confidential.

Harford County At Home HIV Testing Program

Demographics - Part 1

Question Title

* 1. What year were you born? (Required.)

Question Title

* 2. What is your exact birthday? (Required.)

Question Title

* 3. What is your race?

Question Title

* 4. What is your ethnicity?

Question Title

* 5. What is your current health insurance status?

Question Title

* 6. What are the last 4 digits of your Social Security Number, if you have one?This is a unique identifier for your test. It is completely confidential.

1. What year were you born? (Required.)

2. What is your exact birthday? (Required.)

3. What is your race?

4. What is your ethnicity?

5. What is your current health insurance status?

6. What are the last 4 digits of your Social Security Number, if you have one?
This is a unique identifier for your test. It is completely confidential.