Please complete the following HIV Testing Risk Assessment form.Testing Risk Assessment EmailThis field is for validation purposes and should be left unchanged.Date(Required) MM slash DD slash YYYY Name(Required) First (chosen/preferred) Last Date of Birth(Required) Month Day Year Valid Phone #(Required)Valid Email(Required)What is your preferred method of contact?(Required) Phone call Text message Email We will contact you by your preferred method for but not limited to the following: Send Tracking Number. Provide PrEP Resources. Provide Linkage Resources. Valid Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What is your gender identity?(Required) Cisgender Male (assigned male at birth) Cisgender Female (assigned female at birth) Trans Male Trans Female Intersex Gender Nonconforming/Non-binary Other What is your sexual orientation?(Required) Heterosexual Gay Bisexual Same Gender Loving Queer Asexual Other What is your race/ethinicity?(Required) Black / African American Hispanic / Latinx Native American / Indigenous Hawaiian / Pacific Islander White Asian Other How did you hear about this self-screening program?(Required) Facebook: The Normal Anomaly Twitter: @_NormalAnomaly Instagram: @thenormalanomaly Website: normalanomaly.org Friend/Family Community Based Organization Walk-in Other Check all that apply.How did you hear about this testing program?: OtherHow often do you get tested?(Required) 4 times a year 3 times a year 2 times a year Once a year Less than once a year Never been tested Are you familiar with PrEP?(Required) Yes, I am currently taking PrEP Yes, but not currently taking PrEP No, have little information on PrEP No, never heard of PrEP Do you currently have health insurance? Yes No Unsure Compensation agreement I agree to use the email providedI understand that I will receive compensation for the self-screening kit in the form of a physical in-person or a virtual gift card to the email I provided.Consent I agree to the privacy policy.I understand that this is a self-screening kit, and that compensation will be provided after the kit is completed (INSTI or OraQuick) or once confirmation is received that myLAB Box has received my returned kit. I consent to being contacted by The Normal Anomaly Initiative staff through my preferred contact method for the purpose of providing information about potential resources, treatment options, results, and compensation. Our team respects your privacy and will always make every effort to communicate with the utmost discretion.Anti-SPAM: What is 6 + 4?(Required)
