Do you Consider Yourself:
Gay
Lesbian
Heterosexual/Straight
Bi-Sexual
Transgender
What is Your Gender?
Male
Female
What Age Group Are You In?
18-24
25-44
45-64
65+
When is your birthday (mm/dd)?
What is Your Race?
American Indian/Alaska
Asian/Pacific Islander
Black
White
Multracial
Unknown
What is your Ethnicity?
Hispanic-Caribbean
Hispanic-Central
Hispanic-South
Hispanic-Origin unknown/other
Haitian
All othr Ethnicities
Is Your Main Residence Key West/Monroe County?
Yes
No
I am a tourist
How About MY Story?
Liked it/Want an HIV Test
My Behavior needs change
You achieved your goal
I will give it some thought
Totally Ineffective
Last Internet Hook Up for Sex?
Less than 1 month ago
1-3 months ago
More than 3 months ago
Never
May We Contact You by E-Mail?
Yes
No
(Optional) Email Address:
Comments:
Indicates Response Required
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