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It records demographic details including date of birth, sex at birth, current gender identity, ethnicity, race, and residence zip code. It asks about prior HIV testing and prior results, then documents sexual history with male, female, and transgender partners, including condom use and HIV status, over the past five years. It also covers injection drug use, sharing equipment, PrEP awareness and current use, and includes navigator-only sections for essential health benefits navigation, screening, and 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Today’s Date: / / |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| Date of Birth:\u003Cbr>/ / |  | State Where You Live |  |  | County Where You Live |  | Your Zip Code |\n| Ethnicity\u003Cbr> Hispanic or Latino  Not Hispanic or Latino | Race (Check all that apply)\u003Cbr> American Indian/Alaska Native\u003Cbr> Asian\u003Cbr> Black/African American\u003Cbr> Native Hawaiian/Pacific Islander  White\u003Cbr> Not specified |  |  |  | Sex at Birth\u003Cbr> Male  Female | Current Gender Identity\u003Cbr> Male\u003Cbr> Female\u003Cbr> Transgender Male to Female (MTF)  Transgender Female to Male (FTM)  Transgender-Unspecified\u003Cbr> Another Gender |  |\n| Have you ever been tested for HIV previously?\u003Cbr> Yes  No  Don’t know |  |  |  | If you have been tested for HIV before, what was the result?\u003Cbr> Negative  Positive  Don’t know |  |  |  |\n\nTest ID A\\# Sticker Here  \nTo the best of your knowledge, in the past 5 years have you:  \n\n| Had vaginal or anal sex with a male?\u003Cbr> Yes  No\u003Cbr>Had vaginal or anal sex with a male without using a condom?\u003Cbr> Yes  No\u003Cbr>Had vaginal or anal sex with a male who injects drugs?\u003Cbr> Yes  No\u003Cbr>Had vaginal or anal sex with a male\u003Cbr>who is HIV+?\u003Cbr> Yes  No | Had vaginal or anal sex with a female?\u003Cbr> Yes  No\u003Cbr>Had vaginal or anal sex with a female without using a condom?\u003Cbr> Yes  No\u003Cbr>Had vaginal or anal sex with a female who injects drugs?\u003Cbr> Yes  No\u003Cbr>Had vaginal or anal sex with a female\u003Cbr>who is HIV+?\u003Cbr> Yes  No | Had vaginal or anal sex with a transgender person?\u003Cbr> Yes  No\u003Cbr>Had vaginal or anal sex with a transgender person without using a condom?\u003Cbr> Yes  No\u003Cbr>Had vaginal or anal sex with a transgender person who injects drugs?\u003Cbr> Yes  No\u003Cbr>Had vaginal or anal sex with a transgender person\u003Cbr>who is HIV+?\u003Cbr> Yes  No |\n| --- | --- | --- |\n\nTo the best of your knowledge, in the past 5 years have you:  \nInjected drugs?  Yes  No  \nShared injection drug use equipment?  Yes  No  \nCheck the box for yes: (Check all that apply)  \n Have you ever heard of PrEP (Pre-Exposure Prophylaxis)?  Are you currently taking daily PrEP medication?  \n Have you used PrEP any time in the last 12 months?  \nF-02436A (02/2020) Page 2  \nPrEP QUESTIONNAIRE  \n\n|  | \u003Cbr>For PrEP Navigators Only\u003Cbr>Essential Health Benefits: (Check box for yes , check all that apply) |  |  |\n| --- | --- | --- | --- |\n|  | Screened for Need | Need Determined | Provided or Referred |\n|  | Health benefits navigation and enrollment    |  |  |\n|  | Evidence-based risk reduction intervention    |  |  |\n|  | Behavioral health services    |  |  |\n|  | Social services    |  |  |\n|  | Local Use Fields\u003Cbr>Worker Name: (Enter in Local Use Field 1)   Referral Source: (Enter in Local Use Field 2)   |  |  |","cbCais4x0L2bGHdr","https://ap.wps.com/l/cbCais4x0L2bGHdr","pdf",188663,"English","# PrEP Questionnaire\n## Demographics and Residence\n## Prior HIV Testing\n## Sexual Risk History (Past 5 Years)\n## Injection Drug Use\n## PrEP Awareness and Usage\n## Navigator-Only: Essential Health Benefits","[{\"question\":\"What personal information does the questionnaire collect?\",\"answer\":\"It collects date of birth, state where you live, county, zip code, ethnicity, race, sex at birth, and current gender identity.\"},{\"question\":\"Which HIV testing questions are included?\",\"answer\":\"It asks whether you have been tested for HIV previously and, if so, the prior result (negative, positive, or don’t know).\"},{\"question\":\"What risk behaviors are assessed for PrEP eligibility support?\",\"answer\":\"It covers sexual activity with male, female, and transgender partners (including condom use and partner HIV+ status) and injection drug use, including whether equipment was shared, plus PrEP awareness and use in the last 12 months.\"}]","PrEP Questionnaire | PDF",1790527650]