Qualification Survey-At Home HIV Test Kit

Thank you for your interest in the free HIV at home self-testing kit.

The test you’ll receive in the mail is an OraQuick Oral Antibody test; it is performed by placing a swab on the lining of your mouth. Results take 20 minutes to process. Please complete the below details and click the submit button at the end of the form. If you have any questions, please contact the Florida Department of Health in Broward County at 954-847-8132. Please note the program is only available to Broward residents.

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* 1. Are you a Broward County Resident?

Yes

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* 2. Were you referred to this site by a local organization?

Yes

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* 3. If yes, please provide name of agency.

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* 4. When were you last tested for HIV?

Less than 12 months ago

More than 12 months ago

I have never been tested

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* 5. Name

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* 6. Email

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* 7. Phone Number

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* 8. Age

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* 9. Address

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* 10. Country of Birth

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* 11. Please identify your gender

Male

Female

Trans (Male to Female)

Trans (Female to Male)

Genderqueer

Non-binary

Other

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* 12. Please identify your race/ethnicity

Non-Hispanic White

Non-Hispanic Black

Hispanic

Asian/Hawaiian Pacific Islander

American Indian/Alaska Native

Multiracial

Other