STI Self-Testing Kit Form Fill this form out to receive a free self-testing kit which screens for: CHLAMYDIA GONORRHEA HEPATITIS C (Hep C) HIV (I & II) HERPES SIMPLEX 2 SYPHILIS TRICHOMONIASIS (Trich) Our center responds within 24-48 hours. Monday- Saturday 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 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 testing 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?: Other How 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 Do you know your HIV status?(Required) Yes, HIV positive Yes, HIV negative No, unsure Never been tested for HIV before Prefer not to disclose 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 Employment status(Required) Employed full-time Not employed Student Self employed Employed part-time Other Living situation (where do you slept most nights in the past 3 months)(Required) Home or Apartment (rent/own) Homeless shelter/ Transitional housing/ Halfway house Jail/Nursing home/Recovery center Outside/ On the streets Prefer not say Other Check all that apply.Living situation: Other Anti-SPAM: What is 6 + 4?(Required) PhoneThis field is for validation purposes and should be left unchanged.
