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Exit Survey
 
 
I am
 
Male
 
Female
 
Transgender M to F
 
Transgender F to M
 
Don't know
 
Refused
 
Missing
 
 
How old are you?
 
 
How would you describe your race and ethnicity?
 
American Indian/Alaska Native
 
Asian
 
Black, non-Hispanic
 
Hispanic
 
Native Hawaiian/Other Pacific Islander
 
White, non-Hispanic
 
Multiple races
 
Don't know
 
Refused
 
Missing
 
 
• What language do you feel most comfortable speaking?
 
English
 
Spanish
 
Other
 
 
 
What is your current marital status?
 
Single/Living alone
 
Married
 
Living with a partner/significant other
 
Divorced/separated
 
Widowed
 
 
If female, are you currently pregnant, or have you been pregnant within the last 12 months?
 
Yes
 
No
 
 
If your baby has been born, is s/he seeing a doctor?
 
Yes
 
No
 
My baby has not yet been born
 
 
If YES, are you currently receiving or did you receive any medication to prevent transmission of HIV from you to your baby?
 
Yes
 
No