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SURVEY CONSENT

This survey is anonymous and will not be asked your name or any other personal information during this process.
Completion of this survey indicates your willingness to take part in this study and that you are at least 18 years old.
By answering the following questions you agree with our Informed Consent and a PDF with these terms, will be downloaded automatically.

Do you confirm that you are at least 18 years old and agree to participate by completing this online survey?

Do you understand that your participation is completely voluntary and you do not have to answer any survey questions you do not want to answer and that your name will in no way be associated with the research findings?

Do you currently live in the United States or United States Territory?

How would you describe your ability status?

For purposes of this survey, a disability is defined as: Any physical or mental impairment that substantially limits one or more major life activities, and can include, but is not limited to: non-obvious, chronic conditions such as cancer, diabetes, lupus, fibromyalgia, epilepsy, clinical depression, and alcoholism.

In what month were you born?

In what year were you born?

What is your zip code?



What is your gender? Do you identify as:

Please describe your race/ethnicity. Please mark one.

Are you deaf, or do you have serious difficulty hearing?

Is anyone blind or does anyone have serious difficulty seeing even when wearing glasses?

Because of a physical, mental, or emotional condition, does anyone have serious difficulty concentrating, remembering, or making decisions?

Does anyone have serious difficulty walking or climbing stairs?

Does anyone have difficulty dressing or bathing?

Because of a physical, mental, or emotional condition, does anyone have difficulty doing errands alone such as visiting a doctor’s office or shopping?

What is the highest level of school you attended: primary, middle school, or higher?

Have you done any work in the last seven days for which you received cash as payment?

What is your marital status now: are you married, living together with someone as if married, widowed, divorced, or separated?

About how long has it been since you last saw a doctor or other health professional about your health?

Is there a place that you usually go to if you are sick and need health care?

What kind of place - a doctor´s office or health center; an urgent care center, a clinic in a drug store or grocery store; a hospital emergency room; a VA Medical Center or VA outpatient clinic; or some other place? Check all that apply.

At your last medical care visit, did you have a chance to speak with a doctor or other health professional privately, without a caregiver in the room?

At your last medical care visit, did your health care provider had the chance to discuss with you about HIV prevention methods?

In your last visit, has your health care provider discussed with you any of the following? Check all that apply.

When was the last time you had a health care provider (a doctor, nurse, or other health professional) discuss with you about HIV prevention methods?

At your last medical care visit, did your health care provider offered you an HIV test?

When was the last time a health care provider (a doctor, nurse, or other health professional) offered you an HIV test?

Why have you never been tested for HIV? Select all that apply.

During your last HIV test, were you satisfied with the services?

What are the reasons why you were dissatisfied with the services? Select all that apply.

With a self‐test kit you can test yourself for HIV at home. There are instructions on how to interpret the results. Have you ever tested yourself for HIV in private using a self‐test kit?

When was the last time you used an HIV self test kit?

Do you think that your chances of getting HIV are: no risk, small risk, moderate risk or great risk?

Do you think that disabled people might be at risk for HIV?

Do you think that disabled people are at greater risk for HIV/AIDS than non-disabled people?

Why do you feel patients with disability are at moderate or great risk of acquiring HIV? Check all that apply.

“PrEP” or pre‐exposure prophylaxis, is daily medicine that can reduce your chance of getting HIV. Have you ever heard of PrEP before now?

Where have you heard about PrEP? Check all that apply.

Have you ever taken PrEP?

“PEP” or post‐exposure prophylaxis, is daily medicine that can reduce your chance of getting HIV after exposure to someone of unknown HIV status, or exposure with someone who is HIV‐infected. Have you ever heard of PEP before now?

Have you ever taken PEP?

Do you think the amount of information concerning HIV/AIDS that is reaching the disability community is:

Have there been large HIV Prevention campaigns (by non-disability organizations) that were inaccessible to the people you serve in the following formats? Check all that apply.

Has there been any attempt by non-disabled organizations to put HIV prevention messages into a format that would be more accessible to people living with disabilities?

Do you know any disabled people who were not able to be tested for HIV, or had trouble getting tested because of (check all that apply) :

Do you know any people living with disabilities who could not access health care programs for people with HIV/AIDS or obtain treatment for HIV/AIDS because of their disability?

On a scale from 1 to 5 (1 = very poor, 2 = poor, 3 = neutral, 4 = good and 5 = very good), how would you rate the care you received from health care providers regarding HIV prevention services?

Please think about the accessibility of HIV prevention services at your local hospital (or provider):

If you would like to be contacted to participate in the key informant interview, please leave your email here