POL Outreach Form | www.lgbtcleveland.org

Thank you for filling out your demographic information on behalf of the Popular Opinion Leader (POL) program. Data collected is used to report mandatory program statistics, is confidential, and is not associated with any personally-identifying details.

Who did you interact with from the POL Program?

Age

Gender Identity

Sexual Orientation

Race and Ethnicity

Zipcode Zipcode

Household Income

Did you receive outreach materials?

Yes

No

Did you receive an at-home HIV Test Kit?

Yes

No

Where did you receive your at-home HIV Test Kit?

Healthcare Setting

Non-Healthcare Setting

Unknown Test Setting

Is this your first time receiving an HIV test?

Yes, I am a first-time tester.

No, I have been tested for HIV before.

I do not wish to disclose.