SURVEY 7
Have you ever been denied any other service because of your HIV status?
❑ Yes ❑ No 8
Have you ever filed a formal complaint against someone for HIV-related discrimination?
❑ Yes ❑ No 9
Have you ever stood up to someone for HIV-related discrimination?
❑ Yes ❑ No 10 Has fear of HIV-related stigma or discrimination prevented you from disclosing to any of the following? (Check all that apply.)
❑ Family members or friends ❑ Boss or coworkers ❑ Potential sexual partners ❑ Health care professionals 11
DEALING WITH
DISCRIMINATION
HIV-related stigma and discrimination come in many forms and pose some of the greatest challenges of the epidemic. They affect a person’s ability to access education, care, support and treatment. POZ wants to know: Have you ever had to deal with discrimination?
ISTOCKPHOTO.COM/CATALIN PLESA (MODEL USED FOR ILLUSTRATIVE PURPOSES ONLY)
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❑ Yes ❑ No 12
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What year were you born?__ __ __ __
Have you ever experienced HIV-related discrimination from a friend or family member?
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What is your gender?
Have you ever experienced HIV-related discrimination at your workplace?
Have you ever experienced HIV-related discrimination at a doctor’s office or other health care facility?
Have you ever experienced HIV-related discrimination at your church or place of worship?
❑ Yes ❑ No 6
❑ Lack of education ❑ Other
❑ Yes ❑ No
❑ Yes ❑ No 5
What do you think is the biggest driver of HIV-related stigma and discrimination?
❑ Fear ❑ Homophobia
Have you ever experienced discrimination because of your HIV status?
❑ Male ❑ Female ❑ Transgender ❑ Other 16 What is your sexual orientation?
❑ Straight ❑ Bisexual ❑ Gay/lesbian ❑ Other
❑ Yes ❑ No 4
Do you think the HIV/AIDS community is doing enough to fight stigma and discrimination?
❑ Yes ❑ No
❑ Yes ❑ No 3
Has fear of HIV-related stigma or discrimination prevented you from seeking care or treatment?
Have you ever been denied housing or accommodations because of your HIV status?
❑ Yes ❑ No
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What is your ethnicity? (Check all that apply.)
❑ American Indian or Alaska Native ❑ Arab or Middle Eastern ❑ Asian ❑ Black or African American ❑ Hispanic or Latino ❑ Native Hawaiian or other Pacific Islander ❑ White ❑ Other (please specify):___________________ 18 What is your ZIP code? __ __ __ __ __
Please fill out this confidential survey at poz.com/survey or mail it to: Smart + Strong, ATTN: POZ Survey #184, 462 Seventh Avenue, 19th Floor, New York, NY 10018-7424